Injection Technique Training Research Articles

Do Сovid-19 vaccines cause shoulder injuries: a survey among health care providers at Najran University hospital

Background: Shoulder injury related to vaccine administration (SIRVA) is a rare but serious side effect of the COVID-19 vaccine. The incidence of SIRVA among healthcare providers is not well understood. Aim: To investigate the incidence of SIRVA among healthcare providers working at a National University Hospital in Saudi Arabia and to assess their knowledge of SIRVA. Methodology: A cross-sectional online survey was distributed to all licensed healthcare providers currently employed by the National University Hospital. The survey collected information on personal, professional, and demographic characteristics, as well as symptoms and experiences related to SIRVA. Results: Of the 81 participants, 69.1% reported experiencing pain in their shoulder after receiving the COVID-19 vaccine, with 50% rating their pain as average (4-6 on a scale of 1-10) and 41.1% rating their pain as severe (7-10). Only 4.9% of participants reported visiting an orthopedic clinic for SIRVA and 76.5% did not receive treatment for their symptoms. A majority of participants (58%) believed that SIRVA occurs when the vaccine is injected too high up on the upper arm, with 34.6% believing it occurs in the middle of the upper arm and 7.4% believing it occurs too low down on the upper arm. It was also found that only 14.3% of participants were able to correctly identify the cause of SIRVA as accidental injection into the subdeltoid bursa. Additionally, a majority of participants believed that SIRVA is a rare condition (49.4%), and only a small percentage had received training about SIRVA (5.9%). Conclusions: These findings indicate a significant incidence of SIRVA among healthcare providers working at the National University Hospital and highlight the need for increased education and awareness about SIRVA among healthcare providers, as well as proper training in injection techniques to reduce the incidence of SIRVA.

Lipodystrophy in children with type 1 diabetes mellitus and variability of glycemia

Objective — to optimize the prevention of complications of type 1 diabetes mellitus (DM 1) by diagnosing and preventing insulin­induced lipodystrophy (LD) and studying the effects of injection technique on glycemic variability. Materials and methods. The study included 235 patients with DM 1 aged 6—17 years (mean age 13.6 years) who were treated in the Department of Endocrinology of the Institute of Health Protection of Children and Adolescents NAMS of Ukraine. From them there were 125 (53.2 %) boys and 110 (46.8 %) girls. The mean DM 1 duration was 5.5 years (1 to 12 years). Patients were divided into two groups: the first consisted of 183 patients with LD (77.9 %), the second group included 52 children without LD (22.2 %). The groups were comparable in the compensation degree, DM duration and gender ratio. The LD was detected visually, by palpation, as well as according to the ultrasound examination (US) of the subcutaneous adipose tissue (SAT) of 385 insulin injection sites using the developed LD screening map. Blood circulation was investigated in the injured sites of SAT. In patients with LD and without it, the glycemic control parameters were calculated taking into account the coefficient of variability (CV) and time when glucose levels corresponded to the target range (time­in­range (TIR)). In case of detection of the pathologically altered SAT, a patient was introduced to the injection technique using short needles (4-5 mm) and indicated the places allowed for insulin injection. The clinical examinations and SAT ultrasound examinations were repeated in 6 months. Results and discussion. After 6 months, the high glycemia variability was revealed in 70 % of patients with LD (CV = 59.5 vs 38.2 %) and lower TIR parameters (TIR = 35.9 vs 55.7 %). TIR values correlated with HbA1c, and variability (CV) levels with the incidence of hypoglycemia and TBR, which was higher in patients with LD. That is 59.3 % of patients with HbA1c to 8.5 % had this figure greater than 50 % (r = 0.017, p < 0.05). The analysis of ultrasonic data from 385 injection sites revealed LD in 78 % of pediatric patients. The presence of various LD forms, caused by violations of injection technique, has been confirmed. Conclusions. With the help of ultrasound examinations of insulin injection sites, early diagnosis of the area of the lesion and the form of LD is possible, which additionally motivated 88 % of patients to follow the rules of insulin administration. It has been proven that timely diagnosis, training and implementation of the correct injection technique resulted in the leveling of the diffuse and mixed LD forms in the majority of patients (62 %). The most important risk factors for the development of insulin induced LD is a violation of injection techniques, namely: insufficient rotation of injection sites, injection of insulin into LD sites, small area of injection site, untimely change and excessive length of needles, namely the use of needles longer than 4—5 mm the number of injections with one needle and the content of the needle in the skin after the injection for more than 10 seconds. Lack of regular training at the School of Diabetes is a determining factor in the formation of low motivation to follow the rules of insulin administration. Thus, training in injection techniques is the basis of lipodystrophy prevention.Keywords: diabetes mellitus, insulin, injections, subcutaneous tissue, lipodystrophy, ultrasound investigation.

Could inadvertent intravenous injection of COVID-19 vaccines cause severe adverse events?

The emergence and rapid spread of COVID-19 led to the development of novel vaccines to fight against the disease. Although COVID-19 vaccines are the major key to controlling the disease and have a good safety profile, they may be associated with some adverse events. Recently, a few studies noted that inadvertent incorrect injection of COVID-19 vaccines may lead to the development of serious adverse events. Herein, we report a case of inadvertent intravenous COVID-19 vaccine injection who developed severe anaphylactic shock following receiving the COVID-19 vaccine. Proper vaccine injection technique training may help to reduce the risk of developing adverse events and improve vaccine safety and efficacy.

Endocrinological carefor children of Kharkiv in the period 2015—2020

The purpose of the work was to analyze the state of medical care for children with endocrine pathology in the city of Kharkov in the period 2015—2019, to analyze the prevalence and structure of diseases of the endocrine system.Materials and methods. The data of the Center for Medical Statistics of the Ministry of Health of Ukraine were used (statistical reporting form 31 «Report on medical care for children»), with mathematical­statistical, bibliosemanticand content analysis.Results and discussion. A new form of endocrinological care for the child population is the creation of a city endocrinological office at a scientific multidisciplinary pediatric institution (State Institution «IOZDPNAMS»), which improved the registration of children, ensured the completeness of medical examination, the appointment of rehabilitation measures. Children who apply to the city endocrinology office have the opportunity to get a free consultation of a neurologist, psychiatrist, psychologist, ophthalmologist, ENT, dentist, gastroenterologist, undergo ultrasound diagnostics, REG, EEG, study at a school for self­monitoring of diabetes mellitusand obesity on the basis of the State Institution «IOZDPNAMS» In patients with diabetes mellitus and labile course, it is possible to control diabetes both by test systems and to carry out professional monitoring of glycemia free of charge at home, with an analysis of glycemic indicators by an endocrinologist.Conclusion. The most common endocrine pathology among all children of the city endocrinology office is type 1 diabetes. The specialists of the State Institution «IOZDPNAMS» have proposed an algorithm for staged support of children with type 1 diabetes, which includes glucose monitoring, training in injection techniques and increasing knowledge about diet and daily routine, physical activity. Also, for practical use, there are examples of calculations of some individual indicators, including in the presence of flash monitoring in a child. This will help to optimize the work of primary care specialists in helping children with endocrine pathology.

52-LB: Insulin Cost-Saving Estimate for Injection Technique (IT) Training in Subjects Injecting into Lipohypertrophy (LH)

Background: LH with prevalence of 53.1% [1] among diabetic population in China, is one of the most common clinical complications related to injection therapy. IT training includes rotation of injection sites, adjustment of doses, stop needle reuse, etc. is an education intervention for those diabetic patients injecting into LH. Objective: This study aims to assess the effect of IT training on Total Daily Dose (TDD) of insulin for those diabetic patients injecting into LH and estimate the related insulin cost savings. Methods: A 6-month prospective randomized controlled trial carried out in 210 diabetic patients with LH in Tianjin. Patients in intervention group (n=106) were given IT training including avoiding injections into LH, reducing TDD by 10-20%, rotating injection sites, and stopping needle reuse. Patients in control group (n=104) kept their injection habits. The annual cost of insulin in China were calculated with the TDD, unit cost of insulin, the population of insulin therapy and insulin adherence rate. Unit costs of insulin was 0.25 RMB/IU [2], 9 million insulin injecting patients and 42% insulin therapy adherence in China [1] (the exchange rate is 1 USD =6.617 RMB in 2018). The discount rate was set as 3%. Results: The TDD for the control group and intervention group were 45.31(21.83) IU and 47.08(20.62) IU at 0 month and 45.06(21.29) IU and 40.53(19.97) IU at 6 months respectively. Patients in intervention group had a significant TDD decrease at 6.84 IU per day (P<0.05) after 6 months training. However, the TDD for control group only decreased at 0.91 IU per day. The estimated annual cost of decrease of insulin uptake because of IT training is approximately 1.37 billion RMB (207.0 million USD). Conclusion: IT training in patients with LH can significantly reduce the insulin uptake and then saving medical expenditure both from the patient and the healthcare sectors’ perspective. Thus, the IT training should be applied in a greater population with insulin therapy in China. Disclosure L. Chen: Research Support; Self; Becton, Dickinson and Company. Q. Xing: Research Support; Self; Becton, Dickinson and Company. J. Li: Research Support; Self; Becton, Dickinson and Company. J. Zhou: Research Support; Self; Becton, Dickinson and Company. Y. Hou: Employee; Self; Becton, Dickinson and Company. N. Yue: Employee; Self; Becton, Dickinson and Company. Y. Yuan: Employee; Self; Becton, Dickinson and Company. Funding Becton, Dickinson and Company

337-OR: Injection Technique (IT) Training in Subjects Injecting into Lipohypertrophy (LH)—The Tianjin Randomized Controlled Trial (RCT)

Rationale: LH is a common local complication of insulin injection. We conducted a 6-month prospective RCT to assess effects of intensive IT training vs. usual care on HbA1c, TDD insulin, LH lesions, injection behavior and BG variability. Methods: Adult subjects injecting into LH lesions were randomized to usual care (N=104), or intensive IT training (N=106): stop LH injections, lower TDD insulin 10-20%, properly rotate injections within and between sites, and reduce needle reuse. The 2 groups saw different study staff to avoid injection practice contamination in Controls. Results: Subjects were well matched for (mean ± SD) insulin injection duration (7.0 ± 5.0 years); HbA1c (8.5 ± 1.1%); TDD insulin (46.2 ± 21.2 IU); LH lesion count (1.9 ± 0.4), strict correct site rotation (2.9%), and factors such as age, BMI, needle reuse (% and frequency), daily number and sites of injections. Subjects did not perform adequate SBGM to assess BG variability. Due to protocol non-adherence (not lowering TDD in initial IT subjects), and injection behavior contamination in 63 Controls, both ITT and Per Protocol (PP) results are shown. Conclusion: Intensive IT training in subjects who inject into LH lesions can safely lower HbA1c even as TDD insulin is reduced. Conduct of LH RCTs with behavioral education is difficult for both investigators and subjects. Control contamination is likely multi-factorial. Disclosure L. Chen: Research Support; Self; Becton, Dickinson and Company. Q. Xing: Research Support; Self; Becton, Dickinson and Company. J. Li: Research Support; Self; Becton, Dickinson and Company. J. Zhou: Research Support; Self; Becton, Dickinson and Company. Y. Yuan: Employee; Self; Becton, Dickinson and Company. H. Xu: Employee; Self; Becton, Dickinson and Company. Y. Wan: Employee; Self; Becton, Dickinson and Company. B.K. Pflug: Employee; Self; Becton, Dickinson and Company. K. Strauss: Employee; Self; Becton, Dickinson and Company. L. Hirsch: Employee; Self; Becton, Dickinson and Company. Stock/Shareholder; Self; Merck & Co., Inc. Funding Becton, Dickinson and Company

The role of proper insulin injection technique training FOR achieving of good glycaemic control

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.

Botulinum neurotoxin-A usage and training in cervical dystonia & spastic paresis: First results from the Ixcellence Network® survey

Botulinum neurotoxin-A (BoNT-A) is commonly used as first line treatment for Cervical Dystonia (CD) and Spastic Paresis (SP). The Ixcellence Network® (IN) international survey aims to describe the current situation of training and practices among physicians performing BoNT-A injections. A self-completion questionnaire, written by a multidisciplinary steering committee, was completed by experts managing patients with SP and CD, selected from the IN faculty, regarding their experience, training and confidence in different BoNT-A injection techniques and rehabilitation methods. Here we present a partial analysis of the 17 first respondents’ answers. Additional results from a database of more than 700 practitioners (IN attendees) will be available for the congress. Seventeen physicians specialized in physical medicine and rehabilitation (9/17), neurology (7/17) and neuropediatrics (1/17) completed the questionnaire. They reported a mean experience of 22 years in their field (from 14 to 30 years) and 18 years in BoNT-A injection (from 5 to 25 years). All received training prior to first injection, complete with dedicated sessions on guidance techniques: 15 on ultrasound, 11 on anatomical landmarks, 6 on electrostimulation (ES) and 7 on electromyography (EMG). In their current practice, BoNT-A injection was mostly performed without guidance or using ultrasound (16/17 respondents vs 11/17 for ES or EMG). Fifteen physicians also attended specific training on rehabilitation methods for SP (11), CD (1) or both (3). Overall, physicians who followed specific training in injection techniques or in rehabilitation reported greater self-confidence in using them. Training on injection technique and rehabilitation for SP and CD management is variable. Nevertheless, attending specific courses was associated with greater self-confidence. Moreover, physicians mainly used the techniques and methods for which they were trained. These first results highlight the relevance of training in this field.

A Randomized Controlled Trial to Assess the Impact of Proper Insulin Injection Technique Training on Glycemic Control.

IntroductionImproper injection technique can negatively affect glycemic control and treatment tolerability. We assessed the impact of structured insulin injection training on glycemic control.MethodsWe compared changes in glycated hemoglobin (A1C) and fasting plasma glucose following structured insulin injection training in a 6-month pilot study in patients with type 1 or 2 diabetes. Patients were recruited from mobile clinics in Moscow, Russia, and randomized into three groups. Groups 1 and 2 received structured injection training, and group 3 did not. Group 1 received 4-mm needles sufficient for each injection; groups 2 and 3 provided their own needle supply. Changes in insulin total daily dose (TDD), injection technique, needle reuse, and lipohypertrophy (LH) were assessed.ResultsOf 120 patients enrolled, 116 were included in all analyses (group 1, n = 43; group 2, n = 35; group 3, n = 38). At 6 months, mean [95% CI] reductions in A1C were significant in groups 1 and 2 (− 1.00% [10.9 mmol/mol (− 1.3 to − 0.6)] and − 1.00% [10.9 mmol/mol (− 1.4 to − 0.7)], respectively; P < 0.001 for both), but not in group 3 (− 0.02% [0.2 mmol/mol (− 1.2 to 1.6)]). Increases in insulin TDD, however, were similar and significant across groups (approximately 6 IU; P < 0.05). Injection technique improved, and needle reuse and LH declined in groups 1 and 2, but not in group 3.ConclusionsLittle is known about the glycemic impact of insulin injection training. We found that structured training and the use of short pen needles can improve injection technique, leading to significant A1C reductions and decreased rates of LH.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-017-0315-y) contains supplementary material, which is available to authorized users.

Botulinum Toxin in the Treatment of Pediatric Upper Limb Spasticity.

Botulinum neurotoxin (BoNT) is one of the mainstays in the treatment of pediatric spasticity and dystonia. When considering initiation of BoNT treatment for spasticity, treatment goals and responses to prior conservative measures such as passive range of motion exercises, splinting, and other medication trials should be reviewed. As a general rule, children should be engaged in therapy services around the time of the injections and have a robust home program in place. When managing spasticity in children with BoNT injections, the practitioner should be well versed in functional anatomy with specialized training in injection techniques. Localization techniques in addition to anatomical landmarks are recommended for improved efficacy and include limited electromyography, electrical stimulation, and/or ultrasound guidance. A follow-up visit for the purpose of reassessment during the peak effect of the drug is advised. It is known that BoNT is effective at reducing spasticity and improving range of motion, but it remains to be determined to what degree this translates into improved function, activity, and participation.

Emerging permanent filler technologies: focus on Aquamid.

A plethora of soft tissue fillers have been developed within the past decade to correct the cutaneous changes that occur with photoaging. Such fillers, whether nonpermanent, semipermanent, or permanent, are widely used to fill undesired facial rhytides. In addition, fillers are employed to correct atrophy of the face as well as other parts of the body such as the dorsum of the hands through volumization and contouring. The extensive long-term safety outcomes reported with fillers and the ease with which they are administered make them an ideal choice to correct rhytides and to contour the face. However, as with any cosmetic procedure, in order to ensure high patient satisfaction and a safe outcome, proper training in injection techniques, the choice of the proper candidate, and awareness of potential adverse events are essential. This review article focuses on the permanent filler, Aquamid, which is composed of polyacrylamide hydrogel.

Bioequivalence studies for three formulations of a recombinant human growth hormone: Challenges and lessons learned

Two bioequivalence (BE) studies in healthy volunteers comparing new formulations of the recombinant human growth hormone (rhGH) Nutropin AQ (somatropin [rDNA origin] injection; Genentech, Inc., South San Francisco, CA) with the currently marketed formulation (5 mg/mL) were conducted to extend available dosing options. All formulations were administered by subcutaneous (SC) injection ranging in volume from 0.25 to 1.0 mL depending on the formulation concentration. Study A was a 2-period crossover design to assess the BE of 5 and 10 mg/mL. The estimate for relative bioavailability (AUC 0–24 h ) was within the prespecified BE interval (0.80–1.25). However, while the C max estimate (1.17) was contained within the range for BE, the 90% CI (0.986–1.38) extended beyond the prespecified BE interval. As a result, Study A failed to show BE between the 5 and 10 mg/mL formulations. Review of the data showed unexpected increased variability in the observed C max. Further review of individual data suggested that in 4 subjects, the GH concentration profile of 1 of the 2 injections closely resembled the absorption kinetics of an intramuscular injection rather than an SC injection. Because study conduct may have contributed to these results, we performed a second study, Study B. This study incorporated injection technique training, a defined injection site, and a larger sample size to accommodate variability. It also included a third formulation, creating a 3-period crossover design to assess the BE of 2.5, 5, and 10 mg/mL. Study B results demonstrated BE of the new 2.5- and 10-mg/mL formulations to the reference 5-mg/mL formulation, and BE to each other, with all 90% CIs within the BE range of 0.80 to 1.25. Thus the challenge of recognizing that design issues could affect outcomes gave us the tools to perform a second study, and the positive results taught us that demonstrating BE is an issue not only of pharmacology, but also of study methodology and execution.

Home administration of lanreotide Autogel® by patients with acromegaly, or their partners, is safe and effective

ObjectiveThe introduction of ready-to-use lanreotide Autogel® has presented the possibility of patients receiving their acromegaly treatment at home. The objective of this study was to assess the ability of patients (or their partners) to administer repeat, unsupervised, injections of lanreotide Autogel without compromising efficacy or safety.DesignMulticentre (10 UK regional endocrine centres), open-label, nonrandomised, controlled study. Patients elected either to receive/administer unsupervised home injections after injection technique training (Test group) or continued to receive injections from a healthcare professional (Control group). Patients received monthly injections of lanreotide Autogel® at their established dose. Effects were monitored for up to 40 weeks.PatientsThirty patients (15 per treatment group) with acromegaly treated with a stable dose of lanreotide Autogel® (60, 90 or 120 mg) for ≥ 4 months before screening.MeasurementsThe main outcome measure was the proportion of patients/partners who successfully administered injections throughout the study.ResultsAll Test group patients/partners qualified to administer injections. Fourteen of 15 patients fulfilled all criteria for successful administration of unsupervised injections (95% confidence interval, 70%–99%). Fourteen of 15 Test and 14/15 Control patients maintained growth hormone and IGF-1 control. Local injection tolerability was good for both treatment groups, and safety profiles were similar. All Test group patients continued with unsupervised injections after the study.ConclusionsPatients with acromegaly or their partners were able to administer lanreotide Autogel® injections with no detrimental effect on efficacy and safety; therefore, unsupervised home injections are a viable alternative to healthcare professional injections for suitably motivated patients.

The compact Erlangen Active Simulator for Interventional Endoscopy: a prospective comparison in structured team‐training courses on ‘endoscopic hemostasis’ for doctors and nurses to the ‘Endo‐Trainer’ model

Background: In 1997 Hochberger and Neumann presented the ‘Erlangen Biosimulation Model’ (commercialized as the ‘Erlangen Endo‐Trainer’) at various national and international meetings. The new compactEASIE® is a simplified version of the original ‘Biosimulation Model’ (Endo‐Trainer) and is specially designed for easy handling. CompactEASIE is reduced in its features, focusing exclusively on fexible endoscopy training. The acceptance of training in endoscopic hemostasis is accepted by workshop participants, as evaluated by a questionnaire on both models. Methods: Eleven structured courses on endoscopic hemostasis for doctors and nurses organized by the same endoscopists from 3/1998 to 5/1999 were evaluated using one of both models. The questionnaires were filled in by 207/291 trainees (71%). The Endo‐Trainer was used in 4 (n = 103) and the compactEASIE in 7 courses (n = 104). Both simulators were equipped with identical types of specially prepared pig‐organ packages consisting of esophagus, stomach and duodenum, including artificial sewn‐in vessels, polyps and varices. Blood perfusion was done with a roller pump connected to the sewn‐in vessels and blood surrogate. All workshops were identical concerning the course structure: a 30‐min theoretical introduction on ulcer bleeding was followed by 2 h of practical training in injection techniques and hemoclip application. The second part of variceal therapy consisted of a 30‐min theoretical introduction prior to 2 h of practical training on sclerotherapy, band ligation and cyanoacrylate application. Finally, a questionnaire on the trainees' pre‐experience and their rating of the different workshop sections was handed out to each participant. Results: Previous endoscopic experience was comparable in both groups. The training in both simulators was highly accepted by the trainees (compactEASIE 95% excellent and good versus EASIE (Endo‐Trainer) 97%) and did not show any significant difference (P = 0.493). Even in the assessment of the single techniques, no statistical difference was observed. Furthermore, the assessments of the closeness to reality and the endoscopic environment in both simulators were identical. Conclusions: Both simulators (Endo‐Trainer, compactEASIE) are excellent educational tools for interventional endoscopy with a high level of acceptance. The easy‐to‐handle, ‘lightweight’ compactEASIE is a significant, progress tool for the future.