Search

Introduction: The most frequent local complication of insulin injection is the occurrence of subcutaneous nodules due to incorrect injection technique. Injection into nodules negatively impacts metabolic compensation and the requirement for greater insulin doses due to its partial and erratic absorption. Despite these concepts being accepted by the scientific community, it is not yet clear whether injection into nodules is causally related to worsening chronic diabetes (DM) complications and the morphological nature of such nodules. Aim: This multicenter study aimed to evaluate the associations between structural characteristics of skin nodules and chronic DM complications. A secondary endpoint was to evaluate the histological structure of those nodules, looking for differences between lipohypertrophies (LH) and amyloid nodules (LIDA). Methods: For this purpose, 816 DM patients with LH and 1033 without LH underwent a clinical and ultrasound study comparing metabolic data, injection habits, and frequency of complications. Excisional biopsies of the skin nodules were performed in a small series of eight subjects. Results: Data observed confirm a strong relationship between LH and diabetes chronic complications other than poor glycemic control. Histology of biopsies from the skin nodules showed mild foreign-body-like inflammation, prevailing mega-adipocytes (65%), apoptosis, and fibrosis but could not detect any amyloid fibrils. In four cases, intra-nodular fluid was present with an insulin concentration several times higher than in blood. Conclusions: We confirmed LHs to be significantly associated with insulin administration errors, duration of insulin therapy, greater daily doses and duration of insulin administration, and the presence of micro- and macro-vascular DM complications. LH nodules displayed no typical morphological features and were indistinguishable from LIDA nodules with which they shared several histologic similarities, albeit within the frame of a general picture of LIDA inhomogeneity. Further targeted studies are warranted to clarify the remaining doubts.

Introduction: The nasal region plays a pivotal role in both facial esthetics and functionality. The use of volumizing fillers has emerged as a potential means to enhance nasal appearance. Preliminary findings from cadaveric studies have highlighted potential risks associated with deeper needle injection, leading to cartilage damage and lateral migration of filler material. Understanding the subcutaneous tissue depth is crucial to prevent such complications and ensure safe filler placement guided by anatomical knowledge. Methods: This study aimed to employ ultrasonographic assessment to precisely measure the depth of soft tissue in the nasal area. Fifty‐two participants without prior nasal surgery or filler injections underwent detailed ultrasonographic evaluation, focusing on seven key anatomical points: Glabellar, Sellion, Rhinion, between Rhinion and Pronasal, Pronasal, between Pronasal and Subnasal, and Subnasal. Results: The ultrasonographic observation revealed varying depths of subcutaneous tissue across these points: Glabellar (4.11 ± 0.79), Sellion (5.21 ± 0.97), Rhinion (2.02 ± 0.74), Rhinion to Pronasal midpoint (6.45 ± 3.1), Pronasal (9.5 ± 2.2), between Pronasal and Subnasal (8.8 ± 0.8), and Subnasal (8.5 ± 0.5). Discussion: The discussion underscores the significance of understanding subcutaneous tissue depth in guiding needle length and approach angles during filler injections. This knowledge aids in achieving effective filling while ensuring safe placement within the subcutaneous tissue. [ABSTRACT FROM AUTHOR]

Giulia Lanfranchi,1 Irene Paraboschi,2 Ugo Maria Pierucci,1 Guglielmo Mantica,3 Sara Costanzo,1 Federica Marinoni,1 Andrea Pansini,1 Giorgio Giuseppe Orlando Selvaggio,1 Gloria Pelizzo1,2 1Department of Pediatric Surgery, Buzzi Children’s Hospital, Milan, 20154, Italy; 2Department of Biomedical and Clinical Sciences “L Sacco”, University of Milano, Milan, 20157, Italy; 3Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, 16131, ItalyCorrespondence: Gloria Pelizzo, Department of Biomedical and Clinical Sciences “L Sacco”, University of Milan, Milan, 20157, Italy, Email gloria.pelizzo@unimi.itAim: To review our 10 years of experience with the endoscopic treatment of vesicoureteral reflux (VUR) in children, emphasizing the long-term efficacy of the “combined STING-HIT” technique.Materials and Methods: A retrospective study was performed including all children with symptomatic VUR undergoing the cystoscopic injection of bulking agents from January 2013 to December 2022 in our pediatric tertiary referral center. Three different endoscopic techniques were adopted: the “combined STING-HIT” technique, the STING technique, and the HIT technique. Treatment success was defined as symptom remission and VUR resolution on the voiding cystourethrogram (VCUG) performed at the 3-month follow-up.Results: In the study period, 140 (F:M = 64:76) patients and 228 ureters were treated at a median patient age of 3 (2.0– 6.0) years. After a single endoscopic treatment, VUR resolved in 203 (88%) ureters. The VUR resolution rate after a single endoscopic treatment was 95% (n=70/74) in case of I–II VUR, 88% (n=87/99) in case of III VUR; 83% (n=38/46) in case of IV VUR; 89% (n=8/9) in case of V VUR (p-value: 0.174). Overall, one or two endoscopic treatments succeeded in 219 (96%) ureters. The overall VUR resolution rate following one or two endoscopic treatments was 100% (74/74) in case of I–II VUR, 93% (n=92/99) in case of III VUR; 96% (n=44/46) in case of IV VUR; 100% (n=9/9) in case of V VUR (p-value: 0.083). Despite not being statistically significant, the VUR resolution rate was higher for the “combined STING-HIT” technique, both after one (92%: n=110/119; versus 85%; n=62/73 versus 86%; n=31/36; p-value: 0.225) or two (98%: n=116/119; versus 95%; n=69/73 versus 94%; n=34/36; p-value: 0.469) endoscopic treatments.Conclusion: The endoscopic approaches were highly successful for the treatment of VUR in children. The “combined STING-HIT” technique was a safe and effective procedure, being associated with the higher resolution rate.Keywords: vesicoureteral reflux, injection technique, endoscopic technique, pediatrics

Abstract Introduction IncobotulinumtoxinA (Xeomin®) is used in the treatment of dynamic wrinkles and the aesthetic repositioning of facial structures. The duration of its muscular effect typically extends for around 4 months. However, the residual aesthetic benefit can be observed for a longer period. To date, the long-term aesthetic benefit of incobotulinumtoxinA in facial aesthetics has not been systematically evaluated. This study aimed to evaluate longitudinally the duration and aesthetic benefits of incobotulinumtoxinA in the treatment of the upper face in adult women. Methods A quasi-experimental, evaluator-blind, clinical trial involving 28 adult women (30–60 years old) with facial movement lines, undergoing treatment of the upper face with incobotulinumtoxinA by two injectors, following an individualized protocol (ONE21 and glabellar contraction patterns) was performed. Participants were evaluated on the day of the intervention (day 0) and days 30, 120, 180, and 240, and subjected to standardized photographs. The following outcomes were evaluated blindly at each visit: Merz Aesthetics Facial Contraction Scale (MAS), GAIS (Global Aesthetic Improvement Scale), and patient satisfaction. Adverse effects were evaluated at each visit. Results Participants ranged in age from 30 to 60 years, 93% were self-declared white, and most of their baseline MAS scores for dynamic lines were moderate and severe. All the parameters presented significative reduction from baseline until day 180. At day 240, the dynamic MAS scores were lower than baseline for forehead lines in 15.4% (95% confidence interval (CI) 0.8–30.0%) of the participants, for glabellar lines in 38.5% (95% CI 18.8–58.1%), and for crow’s feet lines in 26.9% (95% CI 9.0–44.8%). Aesthetic improvement compared to baseline was identified in 35% (CI 95% 23‒50%) of the participants at day 240, and 62% (CI 95% 42‒81%) of the sample kept reporting some satisfaction with the procedure. Conclusion The aesthetic treatment of the upper face with incobotulinumtoxinA demonstrates enduring clinical benefits, and patient satisfaction lasting up to 180 days in most participants. The length of efficacy, which exceeded those reported in the literature, may be attributed to the use of techniques based on individualized assessment such as ONE21 and glabellar patterns of contraction.

Purpose: This case report presents a direct composite inverse injection technique using a bi-layer clear mini-index fabricated with a digital workflow to restore extensive posterior occlusal cavities in a 13-year-old patient. Materials and Methods: After a root canal treatment in the right mandibular first molar and step-wise excavation of deep caries in the left mandibular first molar, the extensive occlusal restorations were digitally designed using CAD software, upon which digital wax-ups were 3D-printed. Bi-layer clear mini-indices consisting of a hard outer plastic layer and an elastic inner silicone layer were prepared from the 3D-printed cast. The bonding surfaces were deproteinized using a 6% sodium hypochlorite solution, and an antioxidant (Clearfil DC Activator; Kuraray Noritake) was utilized to improve the dentin bonding durability of a 2-step self-etch adhesive (Clearfil SE Bond 2; Kuraray Noritake). Subsequently, a highly filled universal-shade flowable resin composite (RC) was incrementally placed into the cavities. To create the final occlusal morphology, the same RC was inversely injected through the opening of the bi-layer indices. Results: The workflow was feasible, and the occlusal cavities were efficiently restored using the injection technique. Occlusal carving and adjustments of the morphology were not necessary, leading to less chair time. At the 1-year follow-up, the clinical outcome was excellent. Conclusion: The injection technique with a bi-layer clear mini-index accurately translated the digital wax-ups into large, final restorations. Precise morphology and shortened chair time enhanced patient satisfaction, but at the expense of multiple visits. [ABSTRACT FROM AUTHOR]

Introduction: IncobotulinumtoxinA (Xeomin®) is used in the treatment of dynamic wrinkles and the aesthetic repositioning of facial structures. The duration of its muscular effect typically extends for around 4 months. However, the residual aesthetic benefit can be observed for a longer period. To date, the long-term aesthetic benefit of incobotulinumtoxinA in facial aesthetics has not been systematically evaluated. This study aimed to evaluate longitudinally the duration and aesthetic benefits of incobotulinumtoxinA in the treatment of the upper face in adult women. Methods: A quasi-experimental, evaluator-blind, clinical trial involving 28 adult women (30–60 years old) with facial movement lines, undergoing treatment of the upper face with incobotulinumtoxinA by two injectors, following an individualized protocol (ONE21 and glabellar contraction patterns) was performed. Participants were evaluated on the day of the intervention (day 0) and days 30, 120, 180, and 240, and subjected to standardized photographs. The following outcomes were evaluated blindly at each visit: Merz Aesthetics Facial Contraction Scale (MAS), GAIS (Global Aesthetic Improvement Scale), and patient satisfaction. Adverse effects were evaluated at each visit. Results: Participants ranged in age from 30 to 60 years, 93% were self-declared white, and most of their baseline MAS scores for dynamic lines were moderate and severe. All the parameters presented significative reduction from baseline until day 180. At day 240, the dynamic MAS scores were lower than baseline for forehead lines in 15.4% (95% confidence interval (CI) 0.8–30.0%) of the participants, for glabellar lines in 38.5% (95% CI 18.8–58.1%), and for crow's feet lines in 26.9% (95% CI 9.0–44.8%). Aesthetic improvement compared to baseline was identified in 35% (CI 95% 23‒50%) of the participants at day 240, and 62% (CI 95% 42‒81%) of the sample kept reporting some satisfaction with the procedure. Conclusion: The aesthetic treatment of the upper face with incobotulinumtoxinA demonstrates enduring clinical benefits, and patient satisfaction lasting up to 180 days in most participants. The length of efficacy, which exceeded those reported in the literature, may be attributed to the use of techniques based on individualized assessment such as ONE21 and glabellar patterns of contraction. [ABSTRACT FROM AUTHOR]

Background: Unsafe injection practices pose significant risks to both patients and healthcare providers, constituting a critical issue in global healthcare ensuring the safety and appropriateness of injection practices is imperative. Aim & Objective: This study aimed to comprehensively assess the safety of injection practices across various healthcare facilities. Methodology: A Descriptive survey was conducted during March to December-2021. Non random Purposive sampling technique was adopted to select health care facilities. Total 26 healthcare facilities were selected from Government & private sectors. The study areas were OPDs and indoor wards. An observational checklist used to collect data. Data analysis was done using SPSS-28. Results: A comprehensive assessment revealed commendable adherence to injection safety practices. No deficiencies were found in the availability of resources and materials necessary for injection practices in hospitals. However, certain areas for improvement were identified. Interestingly, the practice of using a fresh pair of gloves for injections was unnoticed in 33% of government facilities and 45% of private facilities, suggesting a possible lapse in infection control protocols. Conclusion: While the healthcare facilities of Surat exhibit commendable adherences to certain aspects of injection safety, there remain opportunities for enhancement. Addressing implementing regular training programs for healthcare providers are crucial steps toward optimizing injection safety practices and ensuring the well-being of both patients and providers. [ABSTRACT FROM AUTHOR]

Knowledge about insulin pen storage significantly and directly affects treatment efficacy and quality for people with type 2 diabetes mellitus. Accurate and complete understanding and practice are vital for properly managing this chronic condition. However, studies on insulin pen use and storage have not been well-researched in Vietnam. This descriptive cross-sectional study aimed to assess the knowledge of people with type 2 diabetes regarding insulin pen use and storage. Data were collected through convenience sampling from 132 people with diabetes at a provincial hospital in Vietnam from September 2022 to May 2023. We developed the Vietnamese Insulin Pen Storage Knowledge Questionnaire (VIPSKQ) based on guidelines, Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India 2021. Data were analyzed using descriptive statistics, the Chi-square test, and binary logistic regression. Results indicated that only 35.6% of participants had good knowledge of insulin pen storage, whereas 64.4% did not. Four factors that affected the participants' understanding of insulin-pen storage were age, education level, duration of diagnosis, and years of treatment for diabetes mellitus. Nurses need to educate people with diabetes to increase their knowledge and skills of insulin pen use and proper storage using various strategies, such as using videos, phone applications, and monitoring their practice regularly. Nurses must also keep abreast of the latest information on insulin treatment modalities and pen storage guidelines. Our questionnaire shows promise for use in practice but needs further testing in different settings with larger groups of individuals with type 2 diabetes. [ABSTRACT FROM AUTHOR]

Pradana Soewondo,1 Ketut Suastika,2 Ida Ayu Kshanti,3 Mardianto Mardianto,4 Sony Wibisono Mudjanarko,5 R Bowo Pramono,6 Dyah Erti Mustikawati7 1Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 2Department of Internal Medicine, Faculty of Medicine, Udayana University, Prof. Dr. I.G.N.G Ngoerah General Hospital Denpasar, Bali, Indonesia; 3Department of Internal Medicine, Fatmawati General Hospital, Jakarta, Indonesia; 4Faculty of Medicine, University of Sumatra Utara/Adam Malik Central Hospital, Internal Medicine, Medan, Indonesia; 5Department of Internal Medicine, Faculty of Medicine Airlangga University, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; 6Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia; 7Ministry of Health Republic of Indonesia, Jakarta, IndonesiaCorrespondence: Pradana Soewondo, Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, Tel +6221 390 7703, Email soewondops@yahoo.comAbstract: The use of insulin for patients with diabetes mellitus in Indonesia appears to be under expectation; moreover, there are gaps in knowledge regarding the proper injection technique and pen needle reuse by both healthcare professionals (HCPs) and patients. To address these issues, a scientific expert meeting was held with the participation of endocrinologists and public health specialist from many different organizations in Indonesia to identify the challenges and problem related to injection technique, high pen needle reuse rate, and the need of all stakeholders. The experts agreed that it is necessary to ensure physicians to start the initiation phase as early as indicated, continue optimizing its dosage to reach targeted blood sugar based on guideline, and involve all relevant stakeholders to improve insulin distribution and patient access in every primary care facility in order to optimize the use of insulin or other injectable diabetes medications in Indonesia. Additionally, the experts believed that education on proper injection technique and improved reuse rate of pen needle is necessary. To date, Indonesian Diabetes Educators Association (IDEA/PEDI) has established guideline on injection technique. There are also recommendations on injection technique and needle reuse from Indonesian Society of Endocrinology (PERKENI) and Forum for Injection Technique & Therapy: Expert Recommendations (FITTER); however, this guideline/recommendation should be disseminated more widely among HCPs. In addition, cost-effectiveness studies based on local data are needed to propose and convince the Payors and other stakeholders. This article can be used as a guidance for HCPs and policymakers to improve current practice on injection technique, pen needle reuse, needle prescription and reimbursement policy in Indonesia and elsewhere.Keywords: diabetes mellitus, expert opinion, GLP-1 receptor agonist, injection technique, insulin, needle reuse

In the present case report, the use of the composite resin injection technique with flowable composite resin was described, aiming to rapidly restore functionality and aesthetics in a patient with severe dental wear. The used technique helped achieve an appropriate morphology, functionality and aesthetics within a reduced execution time. Initially, the teeth were clinically examined, then digital scanning was performed, on the basis of which the 3D wax up model was realized. The obtained model was impressed using a transparent silicone material, so that the silicone guide - on the basis of which the mock-up and, subsequently, the flowable resin injection technique were performed - was made. The results obtained by flowable composite resin injection and wax-up and mock-up techniques are highly satisfactory from an aesthetic, morphological and functional point of view, although the behavior over time should still be evaluated. [ABSTRACT FROM AUTHOR]

Introduction: Proper insulin injection technique is important for optimal glycaemic control, yet patients with diabetes often inject insulin incorrectly. Previous studies identified common errors in insulin injection in Canada, and this article seeks to evaluate the current insulin injection technique practices among patients and explore the effectiveness of feedback and education in improving their technique. Methods: The study recruited 147 patients and 16 physicians across Canada to gather insights into current insulin injection practices and education gaps. Eligible patients were people living with diabetes who inject insulin using an insulin pen and pen needles. Eligible physicians, who were unsupported by diabetes educators, completed a practice assessment survey and selected 10 eligible patients to complete a baseline assessment survey. During the patient visit, if an error in the patient's technique was identified, a pop-up knowledge transfer (KT) prompt would appear, providing feedback and information on best practices at the point of care. Follow-up surveys were completed 1–3 months later. Results: Physicians reported facing barriers to providing education and feedback, including lack of time and personnel, and lack of effective educational material. Patients demonstrated modest improvements in some injection technique domains at their follow-up visit, including injection force factors, time the needle was held in the skin, pen needle reuse, injection area size, and injection angle. The most common initial mistakes by patients were selecting an area smaller than recommended and not paying attention to the injection force. At the second visit, patients reduced an average of one error in their injection technique. Conclusion: Results showed that basic feedback by their physician during one visit could exert moderate improvements on patients' injection technique. Proper injection technique is critical for diabetes management, and incorporating targeted ongoing education and support can significantly enhance physician practices, ultimately reducing risks and improving outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Insulin treatment is widely used not only for type 1 but also for type 2 diabetes patients. Insulin must be injected into the subcutaneous tissue to be effective. The needle length has been shortened for safety and efficiency. However, whether patients use an appropriate needle length is unclear. Methods Skin thickness was measured by ultrasound with patients in their usual posture during injection. Furthermore, the effect of the intervention in which the needle length was changed was investigated. Results Thirty-eight percent of the patients had fluid leakage and injected the needle intradermally. The average skin thickness was 3.3 mm while sitting, which was greater than that in a previous report including measurements taken while lying down. Consequently, the skin thickness was > 4 mm in 9.5% of the patients who used 4-mm needles. Cases of leakage and intradermal injection decreased when the needle length was changed. Conclusions This study identified that the needle length should be considered in patients with thick skin or a lower body mass index due to possibility of intradermal injection.

The effectiveness of therapy in patients with diabetes depends on the correct use of the insulin injection technique. However, despite many established recommendations and evidence that an effective insulin injection technique is essential to improve glycaemic control and minimise the risk associated with diabetes, there is still a need to identify impediments to the insulin injection technique among patients and create awareness among patients and healthcare professionals about the importance of the optimisation of insulin injection techniques. This review focuses on the recent advancements in delivery devices, insulin injection technique teaching methods, monitoring, and complication management and highlights regional best practices and recommendations for optimising injection techniques to improve diabetes outcomes. [ABSTRACT FROM AUTHOR]

Background: Defined as a contour line from the hairline, the zygomatic arch, to the ramus and gonial angle area of the mandible, posterior facial frame (PFF) is an important aesthetic units of the face. With the development of hyaluronic acid fillers and the improvement of injection techniques, minimally invasive injection has become one of the first options to improve PFF. However, effective and systematic injection methods to improve PFF are rarely reported in the literature. Methods: We retrospectively analyzed 200 patients treated with area four technique for PFF. According to the clinical manifestations, PFF was divided into four types, and the injection strategies of the different types were described. GAIS (Global Aesthetic Improvement Scale) at 1 month and 3 months by patients after treatment was evaluated as primary end point. Nine‐item aesthetic assessment scores reviewed by two independent observers with experience were performed. Results: GAIS showed that patients' profile was remarkably improved for 90% of total number of subjects. Before and 3 months after treatment, the assessed scores of the lateral cheek lifting (3.17 ± 0.21 vs. 2.56 ± 0.31) and PFF (3.78 ± 0.56 vs. 2.19 ± 0.48) were statistically significant reduced (p < 0.01). The jawline contouring scale (2.32 ± 0.45 vs. 1.23 ± 0.31) and the lateral cheek fullness scale (3.01 ± 0.23 vs. 2.09 ± 0.17) showed a statistically moderate decrease (p < 0.05). Conclusion: Area four technique provides a safe and convenient method for classifying and treating patients with insufficent PFF, which makes up for the multisite systematic injection of the face. [ABSTRACT FROM AUTHOR]

Ana Lucia Gonzaga da Cunha,1 Rossana Vasconcelos,2 David Di Sessa,3 Gabriel Sampaio,4 Pitila Ramalhoto,5 Bruno F Zampieri,6 Bárbara S Deus,7 Suyan Vasconcelos,8 Talitha Bellote,9 Juiano Carvalho,10 Giseli Petrone,5 Vinicius Figueredo,11 Gustavo Limongi Moreira3 1Clínica Skinline, Santo André, SP, Brazil; 2Nomina Clinica Médica De Cirurgia Plástica, Dermatologia e Oncologia, São Paulo, SP, Brazil; 3DSL Clínica Médica, São Paulo, SP, Brazil; 4Host Clínica, São Paulo, SP, Brazil; 5Private Clinic, Rio de Janeiro, RJ, Brazil; 6Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil; 7Clinica Avatié, São Paulo, SP, Brazil; 8Clinica Splendore, Aracaju, SE, Brazil; 9Instituto La Beautè, Curitiba, PR, Brazil; 10Private Clinic, São Paulo, SP, Brazil; 11Host Clinica, São Paulo, SP, BrazilCorrespondence: Gustavo Limongi Moreira, DSL Clínica Médica, Rua Pamplona 145 / 1717, Jardim Paulista, Sao Paulo, SP, 01405-900, Brazil, Email drgustavolimongi@gmail.comBackground: There is substantial interpersonal variation in the patterns of muscular contraction that substantiates the use of personalized points of application and dosages in clinical practice to achieve optimal results. Nevertheless, there has been no real-life therapeutic series with botulinum toxin for aesthetic treatment of the face in which the subjects were systematically followed to assess its long-term benefit.Purpose: To assess the performance and length of the treatment of glabellar and forehead lines with IncobotulinumtoxinA in a real-life setting.Patients and Methods: We enrolled 20 adults with indications for the treatment of upper facial dynamic lines (glabella and forehead) with botulinum toxin. The protocols of injection points were personalized by the injectors. The participants were photographed under maximum facial contraction before the application (D0) and after 15, 90, 120, and 180 days. The photos were randomly assessed by two blinded experienced raters to consensually grade the dynamic lines according to the Merz Aesthetics Scales (MAS). Efficacy was defined as the reduction in the MAS score.Results: At D15, 18 (90%; 95% CI: 80%– 100%) participants reached the zero score, or a 2-point reduction on the MAS score from the forehead and 16 (80%; 95% CI: 65– 90%) reached that reduction for the glabella. These values from D90 were 14 (70%; 95% CI: 55– 85%) for both sites. At D120, these values were 11 (55%; 95% CI: 35– 75%) and 8 (40%; 95% CI: 25– 55%) for the forehead and glabella. At D180, 10 (50%; 95% CI: 30– 70%) participants presented a MAS score for forehead or glabella dynamic lines lower than the score assessed at D0.Conclusion: As much as 70% of the patients sustained a reduction of scores after 120 days of the treatment for dynamic glabellar and forehead lines. Half of the patients evidenced prolonged benefit at 180 days.Keywords: incobotulinumtoxinA, botulinum toxin, injection technique, ONE21, dynamic wrinkles, upper face, Xeomin

The causes and metabolic consequences of lipohypertrophy (LH) from incorrect insulin injection techniques have been well-known for a long time and are the subject of countless publications. However, only some researchers propose structured research modalities for LH and programs to teach patients how to prevent them and minimize their effects, thus contributing to complete rehabilitation. Experts and scientific societies have produced consensus documents and recommendations to spread the culture of LH and its complications among clinicians. However, they should go deeper into LH detection methods. This short article analyzes the recent literature on the best way to explore and find more or less evident LH lesions by using a structured and validated clinical methodology to benefit the many clinicians without access to technological equipment such as ultrasonography. This text also aims to bring awareness that since the last published recommendations on injection techniques, new needles for insulin injection, more technologically advanced and suitable for specific populations, have come to market but still need a thorough evaluation.

The number of adult individuals with insulin-treated diabetes mellitus (DM) is steadily increasing worldwide. The main local complications of insulin injection are lipohypertrophies (LHs), i.e., subcutaneous nodules consisting of aggregates of macro-adipocytes and fibrin. These nodules result from errors repeatedly made by patients while injecting insulin. Despite being very common, LH lesions/nodules due to incorrect insulin injection techniques are often flat and hardly visible and thus require thorough deep palpation examination and ultrasonography (US) for detection. Identifying LHs is crucial, especially in elderly and frail subjects, because they may eventually result in poor diabetes control due to associated unpredictable insulin release patterns. Raising awareness of the adequate detection of LHs and their clinical consequences is crucial and urgent. A call to action is required on this topic at all levels of undergraduate and postgraduate education.

Background: Insulin treatment is widely used not only for type 1 but also for type 2 diabetes patients. Insulin must be injected into the subcutaneous tissue to be effective. The needle length has been shortened for safety and efficiency. However, whether patients use an appropriate needle length is unclear. Methods: Skin thickness was measured by ultrasound with patients in their usual posture during injection. Furthermore, the effect of the intervention in which the needle length was changed was investigated. Results: Thirty-eight percent of the patients had fluid leakage and injected the needle intradermally. The average skin thickness was 3.3 mm while sitting, which was greater than that in a previous report including measurements taken while lying down. Consequently, the skin thickness was > 4 mm in 9.5% of the patients who used 4-mm needles. Cases of leakage and intradermal injection decreased when the needle length was changed. Conclusions: This study identified that the needle length should be considered in patients with thick skin or a lower body mass index due to possibility of intradermal injection. [ABSTRACT FROM AUTHOR]

Background: There is substantial interpersonal variation in the patterns of muscular contraction that substantiates the use of personalized points of application and dosages in clinical practice to achieve optimal results. Nevertheless, there has been no real-life therapeutic series with botulinum toxin for aesthetic treatment of the face in which the subjects were systematically followed to assess its long-term benefit. Purpose: To assess the performance and length of the treatment of glabellar and forehead lines with IncobotulinumtoxinA in a real-life setting. Patients and Methods: We enrolled 20 adults with indications for the treatment of upper facial dynamic lines (glabella and forehead) with botulinum toxin. The protocols of injection points were personalized by the injectors. The participants were photographed under maximum facial contraction before the application (D0) and after 15, 90, 120, and 180 days. The photos were randomly assessed by two blinded experienced raters to consensually grade the dynamic lines according to the Merz Aesthetics Scales (MAS). Efficacy was defined as the reduction in the MAS score. Results: At D15, 18 (90%; 95% CI: 80%– 100%) participants reached the zero score, or a 2-point reduction on the MAS score from the forehead and 16 (80%; 95% CI: 65– 90%) reached that reduction for the glabella. These values from D90 were 14 (70%; 95% CI: 55– 85%) for both sites. At D120, these values were 11 (55%; 95% CI: 35– 75%) and 8 (40%; 95% CI: 25– 55%) for the forehead and glabella. At D180, 10 (50%; 95% CI: 30– 70%) participants presented a MAS score for forehead or glabella dynamic lines lower than the score assessed at D0. Conclusion: As much as 70% of the patients sustained a reduction of scores after 120 days of the treatment for dynamic glabellar and forehead lines. Half of the patients evidenced prolonged benefit at 180 days. [ABSTRACT FROM AUTHOR]

Abstract Background Ultrasound-guided intertruncal approach (IA) has been proposed to be an alternative and promising approach to the supraclavicular block (SCB), in which double injection (DI) of local anesthetics (LA) is sequentially administered between intertruncal planes. We would like to apply a refined injection technique, named triple injection (TI) technique, based on the 3 separate compartments visualized by ultrasound. The aim of this study is to compare the percentage of patients with complete sensory blockade at 20 min of DI vs TI technique, when they are applied in patients undergoing upper limb arteriovenous access surgery. Methods This study is a prospective parallel-group randomized controlled trial. A total of 86 end-stage renal disease patients will be randomly allocated to receive IA-SCB using either DI or TI technique with identical LA (0.5% ropivacaine 24 mL). The primary outcome is the percentage of patients with complete sensory blockade of all 4 terminal nerves (median, ulnar, radial, and musculocutaneous nerves) of the brachial plexus measured at 20 min after injection. The secondary outcomes will consist of the sensory or motor blockade of all individual nerves, onset times, performance time, diaphragmatic paralysis, surgical anesthesia, and adverse events. Discussion It is expected that ultrasound-guided IA-SCB with the TI technique results in better block dynamic in patients undergoing upper limb arteriovenous access surgery. Trial registration Chinese Clinical Trial Registry ChiCTR2100045075 .

Introduction: Cutaneous lipohypertrophy (LH) is a thickened, "rubbery" lesion in the subcutaneous tissue following multiple injections performed at the same site, i.e., an incorrect injection technique. It is widespread, averaging 47% of insulin patients worldwide, and has severe direct and indirect consequences. Direct consequences consist mainly of poor metabolic control and frequent hypoglycemic events (HYPOs), and indirect ones of markedly increased healthcare costs related to hospital access due to acute events and long-term disease complications. This observation also holds for Italy, despite the National Health System organization expecting every patient with diabetes to undergo a series of visits by different care team members, each performing a specific treatment/education task. Indeed, the recent literature points to poor awareness of LH relevance and metabolic consequences among doctors from general and diabetic hospital wards, with educational deficiencies on correct injection practice in nurses too. The aim was to establish if, to what extent, and by whom they had received training on correct insulin injection techniques, and how many initially received notions had persisted over time. Methods: We investigated the possible causes of such a failure from the point of view of 1160 insulin-requiring subjects with type 2 diabetes (T2DM), reporting for the first time to specialized diabetic structures through a validated questionnaire and, in the same patients, we searched for LH by inspection/palpation according to international guidelines, further confirmed by ultrasound scans. We then analyzed differences in education and injecting behavior between subjects classified as LH+ or LH− depending on the presence or absence of LH lesions. Results: We documented significant educational gaps, with 50% of patients failing to refer to healthcare professionals and relying on their peers with diabetes, thought to be more experienced in 15% of the cases. Seventy-five percent of LH− patients received education from healthcare providers, while 90% of LH+ learned from another patient or could not remember how they knew, and 68% of LH+ versus 52% of LH− (p < 0.01) patients had failed to receive training on injection techniques by healthcare providers. All of this enabled the most disabling features of diabetes from the very beginning of the disease history. Conclusions: This study documents, from the patients' point of view, that educational gaps are significant and that, even in initially trained subjects, education on correct injection techniques has a fleeting effect if not regularly recalled. Therefore, to rehabilitate LH+ patients as soon as possible and prevent LH− patients from inadvertently slipping into the other group, there is an urgent need to educate doctors and nurses repeatedly on the importance of correctly injecting insulin to improve patients' knowledge and skills. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the discrepancy between the diagnostic wax-up and the resulting direct veneers using different matrices. Materials and method: A total of 48 identical misaligned models, 12 wax-up models and one 'every other tooth' wax-up model were 3D printed. Group 1: Transparent silicone matrices with holes for the injection of the flowable composite. Group 2: The same procedure as group 1, but the first three teeth were restored using the matrix constructed from the 'every other tooth' wax-up model. Group 3: Transparent silicone matrices cut for each tooth and preheated resin composite. Group 4: The same procedure as group 3, but the loaded matrix was placed first in the clear plastic tray, which was used for the matrix's fabrication. Group 5: Wax-up models (control group). Scans from the veneers were superimposed with the scans from the wax-up and compared using the Patient Monitoring software. Measurements were made at the incisal, middle and cervical third. Kruskal-Wallis test and Dunn post-hoc test (p < 0.05) were used to analyze the results. Results: No statistically significant differences were found between groups 1 and 2 and the control. Group 3 was different from the control in the incisal and middle third, and group 4 was different in the cervical third. Conclusions: (1) Use of one or two matrices and the injection of flowable composite were accurate techniques. (2) Use of a matrix for each tooth combined with a pre-heated composite was the most inaccurate technique, but the use of the clear tray in combination with the matrix improved the accuracy. [ABSTRACT FROM AUTHOR]

Background: This study introduces a new fluoroscopy-guided intradiscal radiopaque gelified ethanol injection technique using the antero-posterior view and compare it to conventional oblique view. Intradiscal procedures, are minimally invasive techniques that aim to reduce pain associated with lumbar disc herniation by modifying the disc material and decreasing pressure on surrounding nerves., Objectives: This study introduces a new fluoroscopy-guided intradiscal radiopaque gelified ethanol injection technique using an anteroposterior view compared to the conventional oblique view., Study Design: This is a double blind, randomized trial., Setting: A tertiary care center., Methods: Patients with radicular leg pain were randomly assigned to receive a radiopaque gelified ethanol injection via an anteroposterior view or oblique view.. The primary outcomes were procedure time, complication rates, and radiation exposure., Results: A total of 70 patients were randomized to each group (35 for each group). There were no serious complications in either group. Radiation exposure was significantly lower in the anteroposterior view group (36.92 vs 50.46 µGray/m2 [µGy/m2; P = 0.007). The procedure time was also significantly lower in the anteroposterior  group (171 vs 287 seconds; P = 0.001)., Limitations: Limitations of our trial include the relatively small sample size, the single-center nature of the study, and the short follow-up period. We were also limited in only including patients with moderate body habitus, and patients with only L3 or L4 disc herniation, which might restrict the generalizability of the findings., Conclusion: An anteroposterior view radiopaque gelified ethanol injection is a promising alternative to the conventional oblique view technique for radicular leg pain management. This novel approach offers a safer and more efficient treatment option, reducing radiation exposure and procedure time without compromising clinical outcomes. Its potential to minimize patient discomfort and enhance overall management of radicular leg pain warrants further investigation and widespread adoption.

Background: Clinical classification methods for periocular wrinkles based on participating muscle behavior are lacking, and traditional treatment lacks detailed and individualized methods. Aims: This study aimed to propose a modified classification system and individualized treatment for periocular wrinkles based on the participating muscles. Patients/Methods: Periocular wrinkles were classified into types I.I, I.II, I.III, II, and III. A personalized treatment pattern with a multipoint, low‐dose technique was developed based on wrinkle classification and severity. Standard photographs were taken and assessments made at follow‐up to evaluate wrinkle severity. Results: Wrinkle severity was reduced at 1 and 3 months after periorbital botulinum toxin injection, and no serious adverse events were recorded. Conclusions: Periorbital wrinkles were classified according to participating muscles. The modified injection pattern was individualized, effective, and safe for the treatment of periorbital wrinkles. [ABSTRACT FROM AUTHOR]

Lipohypertrophy of the injection site is a common and often-neglected complication of treatment with insulin. It causes unpredictable absorption of the drug, leading to higher glycemic variability. Using the correct injection technique, the lesion may be reversed. Here, we present the case of a patient with type 1 diabetes, whose lipohypertrophy regressed over time. Along with this, the patient also attained better glycemic control and freedom from diabetic ketoacidosis.

Correct insulin administration technique, insulin type, and dose play a pivotal role in attaining glycemic control. An error in any of the steps may lead to poor glycaemic control, which affects the patient in the short and long term. We are presenting here unusual skin findings in children with the wrong injection technique. A 10-year-old male child already diagnosed with type 1 Diabetes Mellitus (DM), presented with poor glycemic control. On examination, we found skin rashes encircling most of his abdominal area circularly. Rashes were round to oval, well-circumscribed, hyperpigmented to hypopigmented to depigmented macules to papules surrounded by a hyperpigmented halo, 0.5 to 1 cm in diameter, painless varying in color from white to pinkish-red to light brown to brownish-black. On observing the administration technique of insulin, we found it was administered incorrectly as intradermal instead of subcutaneous. Proper Diabetes education and insulin administration techniques remain the cornerstone in the management of type 1 DM. We should ensure appropriate insulin administration on every visit.

Background: Facial aging is a complex process, which, beyond a genetic predisposition, involves both physical and environmental factors. Even identical twins with the same genetic load may differ substantially in facial wrinkles and aging, demanding a personalized treatment approach. Objective: To demonstrate the ONE21 technique as an excellent tool to a customized assessment and IncobotulinuntoxinA treatment to address phenotype discordances and epigenetic drifts in identical twins, expressed by different patterns of upper face muscle contractions and wrinkles intensity. Patients/Methods: Five pairs of identical Caucasian twin sisters, from 30 to 45 years of age, were evaluated for hyperfunctional upper facial wrinkles (forehead, glabella, and periorbital), assessing the individual anatomy, muscle function and habitual facial movements of each patient. All the subjects were treated with the ONE21 technique using IncobotulinumtoxinA and reevaluated 30 days after the procedure. Results: Though the clinical‐anatomical pattern of the forehead contraction was similar between the pairs, the strength of the muscles, the number and depth of wrinkles differed. This varied presentation demanded distinct points of distribution and dosages of incobotulinumtoxinA for all the twins, according to the ONE21 approach. The results 30 days after treatment were satisfactory in all the subjects. Conclusion: The ONE21 technique allows an objective and careful evaluation of the wrinkles of the upper face, based on an individualized assessment, which may vary even in identical twins. [ABSTRACT FROM AUTHOR]

Background: Studies of mobile diabetes applications (apps) have demonstrated improvements in glycemia, and patient-reported outcomes (PROs). In addition, shift to shorter pen needles (PN) and guidance on proper injection techniques have shown the potential for reduced glycemic variability. The purpose is to determine the impact of using a diabetes mobile app plus a novel 4 mm PN on PROs and glycemic outcomes in type 2 diabetes mellitus (T2DM) for multiple daily injection (MDI) insulin users. Materials and methods: In this 8-week prospective, parallel-group, randomized controlled trial, subjects either received (1:1) intervention (BD Diabetes Care [DC] App + BD Nano ™ 2nd Gen PN) or control therapy. Controls used their current PN and did not use diabetes apps. Results: Fifty-eight subjects were randomized. Fifty-seven completed the study (intervention n = 27, control n = 30). At study end, there were no significant differences in PROs between groups, except improved medication adherence (ARMS-D) in controls. From flash glucose monitoring (fGM) data, there were no significant differences in most glycemic measures between groups except for a trend for improved glycemic variability [mean amplitude of the glycemic excursions (MAGE)] in the Intervention (p = 0.06). Controls had significantly reduced time spent in hypoglycemia but had 2 to 3-fold higher incidence at baseline. In general, Intervention subjects reported satisfaction with both the app and PN. Conclusions: This is the first BD DC App study, in combination with BD Nano ™ 2nd Gen PN, to assess glycemic outcomes. This combination intervention shows promising results for reduced glycemic variability and the potential to positively impact self-management. [ABSTRACT FROM AUTHOR]

Purpose: Local corticosteroid injections are routinely used as first-line treatment for trigger finger. The accurate delivery of steroids into the tendon sheath is important for the effectiveness of the treatment and the prevention of complications. This study aimed to introduce our steroid injection technique for trigger finger, which uses tendon excursion of the flexor tendon, and evaluate the clinical outcomes in patients who were treated with this technique. Methods: A total of 171 patients with trigger finger who were treated with steroid injections were retrospectively reviewed. The efficacy of injection and complications were investigated. The efficacy was evaluated as "good," "fair," or "poor." The results were analyzed according to the type of finger and the Quinnell grading system. Results: The total efficacy was 83.6% (good/fair, 143 digits; poor, 28 digits). The treat ment success rate for Quinnell grade IV was 43.8% (7 of 16). This rate was significantly lower than those of Quinnell grades II and III, which were 88.9% (88 of 99) and 87.5% (49 of 56), respectively (II vs. IV, p=0.004; III vs. IV, p=0.010). The success rate for the four fingers excluding the thumb was significantly higher than that of the thumb (88.2% vs. 75.4%, p=0.048). Conclusion: The steroid injection technique using tendon excursion showed excellent results and low complication rates. In particular, the second to fourth fingers and cases of low-grade trigger finger showed more effective results. [ABSTRACT FROM AUTHOR]

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

Objective: To compare the efficacy of the innervation zone-targeted injection technique (EUROMUSCULUS/USPRM (Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine) spasticity approach) and the injection technique along the muscle length., Design: A double-blind randomized controlled trial., Setting: Department of rehabilitation medicine of a medical center., Participants: One hundred patients with stroke experiencing ankle plantar flexor spasticity., Interventions: In addition to conventional rehabilitation, eligible patients were randomly assigned to 2 groups. The experimental group was injected with botulinum toxin along the length of the muscle, whereas the control group was injected with the same dose and volume of botulinum toxin 25%-35% proximal to the medial head and 20%-30% proximal to the lateral aspect of the head of the gastrocnemius muscle., Main Outcome Measures: Modified Ashworth scale, modified Tardieu scale, ankle range of motion measurement, and 10-meter walk test were used before and 1 month after injection., Results: The study was completed by 60 participants with a mean age of 59.96±12.15 years. Both injection methods were found to be effective on range of motion, spasticity level, ambulation, and walking speed. There was no statistically significant difference between injection methods., Conclusions: Both injection methods of botulinum toxin A produce similar clinical effects., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Copyright of Journal für Ästhetische Chirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the discrepancy between the diagnostic wax-up and the resulting direct veneers using different matrices. Materials and method: A total of 48 identical misaligned models, 12 wax-up models and one ‘every other tooth’ wax-up model were 3D printed. Group 1: Transparent silicone matrices with holes for the injection of the flowable composite. Group 2: The same procedure as group 1, but the first three teeth were restored using the matrix constructed from the ‘every other tooth’ wax-up model. Group 3: Transparent silicone matrices cut for each tooth and preheated resin composite. Group 4: The same procedure as group 3, but the loaded matrix was placed first in the clear plastic tray, which was used for the matrix’s fabrication. Group 5: Wax-up models (control group). Scans from the veneers were superimposed with the scans from the wax-up and compared using the Patient Monitoring software. Measurements were made at the incisal, middle and cervical third. Kruskal-Wallis test and Dunn post-hoc test (p < 0.05) were used to analyze the results. Results: No statistically significant differences were found between groups 1 and 2 and the control. Group 3 was different from the control in the incisal and middle third, and group 4 was different in the cervical third. Conclusions: (1) Use of one or two matrices and the injection of flowable composite were accurate techniques. (2) Use of a matrix for each tooth combined with a pre-heated composite was the most inaccurate technique, but the use of the clear tray in combination with the matrix improved the accuracy.

Purpose: The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection. Methods: The study cohort consisted of 23 chronic low back pain patients (23–67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy. Results: The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2–3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced. Conclusion: The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique. [ABSTRACT FROM AUTHOR]

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 < 0.001) and size of lipohypertrophic lesions at injection sites (p < 0.02). Conversely, those in the control group progressively abandoned best practice, except for the use of ice-cold insulin and, consequently, had significantly higher HbA1c levels and daily insulin dose requirements at the end of the follow-up than at baseline (p < 0.05). In addition, as expected from all the above, the rate of hypoglycemic episodes also decreased in the intervention group (p < 0.05), resulting in a significant difference between groups after 6 months (p < 0.02). Conclusion: Our data provide evidence that intensive, structured education refresher courses have no outstanding durability, so that repeated refresher courses, at least at 6-month intervals, are needed to have positive effects on people with T2DM, contributing not only to prevention but also to long-term rehabilitation. Trial Registration: Trial Registration no. 118 bis/15.04.2018. [ABSTRACT FROM AUTHOR]

Background: 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. [ABSTRACT FROM AUTHOR]

Carla de Sanctis Pecora Dermatologie-Clínica, Cirurgia, Cosmiatria e Laser, São Paulo, BrazilCorrespondence: Carla de Sanctis Pecora Avenida Ibirapuera, 2907, Conj. 901, Moema, São Paulo, SP CEP: 04029-200, BrazilTel/Fax +55 11 50420871Email carla@dermatologie.com.brAbstract: It is well known that incobotulinumtoxinA (INCO) is an effective approved treatment for dynamic wrinkles of the upper face caused by the action of mimetic muscles over time. In doing so, it is important to maintain a balance between muscle groups and a natural facial appearance. Patients differ enormously in their facial anatomy regarding structure and function, both within and between genders, ethnicities, and age. Therefore, treating all patients with the same injection pattern and the same doses can result in undesired outcomes. There is a need for a tailored approach to achieve optimal results, as well as to increase patient satisfaction. With this in mind, the novel one21 injection technique which allows for individualized treatment has been developed for the treatment of horizontal forehead lines using INCO, resulting in a positive impact on eyebrow position and shape. This technique is the next step in a customized approach, giving natural-looking results and high patient satisfaction.Keywords: incobotulinumtoxinA, botulinum toxin, injection technique, one21, dynamic wrinkles, upper face

Correct insulin administration technique, insulin type, and dose play a pivotal role in attaining glycemic control. An error in any of the steps may lead to poor glycaemic control, which affects the patient in the short and long term. We are presenting here unusual skin findings in children with the wrong injection technique. A 10-year-old male child already diagnosed with type 1 Diabetes Mellitus (DM), presented with poor glycemic control. On examination, we found skin rashes encircling most of his abdominal area circularly. Rashes were round to oval, well-circumscribed, hyperpigmented to hypopigmented to depigmented macules to papules surrounded by a hyperpigmented halo, 0.5 to 1 cm in diameter, painless varying in color from white to pinkish-red to light brown to brownish-black. On observing the administration technique of insulin, we found it was administered incorrectly as intradermal instead of subcutaneous. Proper Diabetes education and insulin administration techniques remain the cornerstone in the management of type 1 DM. We should ensure appropriate insulin administration on every visit. [ABSTRACT FROM AUTHOR]

En dehors du BCG qui doit être obligatoirement effectué en intradermique, tous les autres vaccins injectables pédiatriques peuvent (pour les vaccins vivants) ou doivent (vaccins adjuvés en particulier) être administrés en intramusculaire. Cependant, l'administration en intramusculaire des vaccins n'obéit pas tout à fait aux mêmes règles que les autres injections utilisant le muscle. L'optimisation du confort de la vaccination et la diminution de la douleur liée à l'injection passent d'abord par une technique d'injection adaptée. Or les techniques de vaccination de base peuvent parfois sembler contre intuitives et ne sont pas toutes maîtrisées par les professionnels de santé qui sont amenés à vacciner. Ainsi, l'injection intramusculaire se fait toujours à 90° par rapport au plan de la peau, en utilisant l'aiguille la plus fine possible mais ayant une longueur suffisante pour être certain d'être dans le muscle, sans purger la seringue de son air jusqu'à l'aiguille, sans aspirer au préalable, et en injectant le produit plus rapidement possible. Apart from BCG, which must be administered intradermally, all other pediatric injectable vaccines can (for live vaccines) or must (adjuvanted vaccines in particular) be administered intramuscularly. However, intramuscular administration of vaccines does not follow quite the same rules as other injections using muscle. Optimizing the comfort of the vaccination and reducing the pain associated with the injection requires an adapted injection technique. However, basic vaccination techniques can sometimes seem counter-intuitive and are not all mastered by the health professionals who are called upon to vaccinate. Thus, the intramuscular injection is always done at 90° to the plane of the skin, using a needle as fine as possible but long enough to be sure to be in the muscle, without purging the syringe of its air up to the needle, without first aspirating, and injecting the product as quickly as possible. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]