Standardized Injection Research Articles

Effect of mite-specific subcutaneous immunotherapy on patients with allergic rhinitis

This study analyzed the effect of mite-specific subcutaneous immunotherapy (SCIT) on patients with allergic rhinitis (AR). We enrolled 98 AR patients visiting our hospital from April 2017 to April 2019 and grouped them in a random number table. The control group (n=49) received conventional treatment for three years. The SCIT used a standardized mite allergen injection for the experimental group (n=49) for three years. The study compared total nasal symptom score (TNSS), daily medication score (DMS), total combined score (TCS), visual analog scale (VAS) score, mini-rhinitis quality of life questionnaire (MiniRQLQ) score, and serum immunoglobulin E (sIgE) level before and after treatment. The overall response rate was higher in the experimental group than in the control group (59.18% vs. 30.61%, p<0.05). After treatment, the experimental group had lower values for TCS and VAS score (p<0.05); motion score; practical problems; nasal, ocular, and other symptoms (p<0.05); and sIgE, Dermatophagoides pteronyssinus (Dp)-sIgE, and Dermatophagoides farinae (Df)-sIgE levels (p<0.05) than the control group. The sIgE, Dp-sIgE, and Df-sIgE levels were lower in the effective group than in the ineffective group (p<0.05). The areas under the ROC curves of IgE, Dp-sIgE, and Df-sIgE and their combination for predicting the therapeutic effect of mite-specific SCIT on AR were 0.839, 0.779, 0.814, and 0.903, respectively. Mite-specific SCIT relieved clinical symptoms and improved the quality of life of AR patients, probably by decreasing the IgE expression level.

Assessing the Use of BotulinumtoxinA for Hyperactive Urinary Tract Dysfunction a Decade after Approval: A Single-Blind Study to Evaluate the Reduction in Pain in OnabotulinumtoxinA Detrusor Injection Using Different Injection Needles.

Overactive bladder (OAB) has a significant impact on the quality of life; thus, it requires treatment that can be adhered to over a long period without undue side effects. The current treatment which uses an anticholinergic or β-3 agonist may fail to improve symptoms and has side effects, leading to high discontinuation rates. OnabotulinumtoxinA (OnabotA) detrusor injection has been approved for idiopathic OAB as a second-line treatment with good effectiveness and tolerability. This study used a visual analog scale (VAS) to assess the impact of the type of needle used for OnabotA detrusor injections under local anesthesia on the pain levels after each injection. This study included 68 female patients. We used three different needles with thicknesses ranging from 22 to 27 gauge, lengths between 4 and 5 mm, and different cuts. The sensation of pain was rated at each standardized injection location. Regardless of the needle used, the patients' perceptions of pain at the beginning of the procedure were rated as being less than the subsequent injections. Most pain sensations were rated as low to moderate. The mean pain sensation on the VAS was 2.5 ± 0.3 overall, i.e., for all patients and needles used. Statistically significant differences in pain sensation were rated only at some locations of the bladder (on the back wall and the right side of the bladder). The single needles averaged the following pain scores: 2.8 ± 0.3 for needle A (20 G, 4 mm), 2.1 ± 0.3 for needle B (27 G, 5 mm), and 2.6 ± 0.4 for needle C (20 G, 4 mm, sharp cut 15°). The 27-gauge needle caused significantly less pain, and it had no negative impact due to its length, which was 1 mm longer than the other needles. Thus, the needle thickness was a decisive factor in the patients' perceptions of pain.

Preliminary protocol for measuring the reproducibility and accuracy of flow values on digital PET/CT systems in [15O]H2O myocardial perfusion imaging using a flow phantom

BackgroundSeveral factors may decrease the accuracy of quantitative PET myocardial perfusion imaging (MPI). It is therefore essential to ensure that myocardial blood flow (MBF) values are reproducible and accurate, and to design systematic protocols to achieve this. Until now, no systematic phantom protocols have been available to assess the technical factors affecting measurement accuracy and reproducibility in MPI.Materials and methodsWe implemented a standard measurement protocol, which applies a flow phantom in order to compare image-derived flow values with respect to a ground truth flow value with [15O]H2O MPI performed on both a Discovery MI (DMI-20, GE Healthcare) and a Biograph Vision 600 (Vision-600, Siemens Healthineers) system. Both systems have automatic [15O]H2O radio water generators (Hidex Oy) individually installed, allowing us to also study the differences occurring due to two different bolus delivery systems. To investigate the technical factors contributing to the modelled flow values, we extracted the [15O]H2O bolus profiles, the flow values from the kinetic modeling (Qin and Qout), and finally calculated their differences between test-retest measurements on both systems.ResultsThe measurements performed on the DMI-20 system produced Qin and Qout values corresponging to each other as well as to the reference flow value across all test-retest measurements. The repeatability differences on DMI-20 were 2.1% ± 2.6% and 3.3% ± 4.1% for Qin and Qout, respectively. On Vision-600 they were 10% ± 8.4% and 11% ± 10% for Qin and Qout, respectively. The measurements performed on the Vision-600 system showed more variation between Qin and Qout values across test-retest measurements and exceeded 15% difference in 7/24 of the measurements.ConclusionsA preliminary protocol for measuring the accuracy and reproducibility of flow values in [15O]H2O MPI between digital PET/CT systems was assessed. The test-retest reproducibility falls below 15% in majority of the measurements conducted between two individual injector systems and two digital PET/CT systems. This study highlights the importance of implementing a standardized bolus injection and delivery protocol and importance of assessing technical factors affecting flow value reproducibility, which should be carefully investigated in a multi-center setting.

Advancing the Era of Liquid Rhinoplasty: A Methodological Approach to Injection Protocols.

Liquid rhinoplasty, a non-surgical procedure using hyaluronic acid (HA) to reshape and refine the nose, has gained in popularity as an alternative to traditional surgical rhinoplasty although its results are not definitive. However, the lack of standardized injection protocols has raised concerns about treatment consistency and patient safety. In this article, the authors propose a systematic protocol for the most common indications of liquid rhinoplasty. By adopting a standardized methodology, healthcare professionals can enhance patient safety, improve treatment consistency, and optimize patient satisfaction. The protocol includes standardized injection sites categorized as dorsal, paramedian, tip and endonasal injections. Specific injection areas are recommended for different nasal shapes such as droopy noses, dorsal humps, nasal saddle deformity, inverted V deformity, tip shape abnormalities, twisted noses, revision cases with dorsal irregularities, and internal nasal valve dysfunction. While variations in filler dosages may be necessary based on individual patient needs, a conservative approach is recommended to maintain natural-looking results and reduce the risk of complications. The increase in non-surgical techniques for nasal refinement offers patients more options, and systematized injection protocols based on different nasal types provide a structured framework for liquid rhinoplasty. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections

ObjectivesImage-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization. MethodsA consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed. ResultsA standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 ​s. There were no patient-related variables associated with nonintra-articular injections in the cohort. ConclusionsThis study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 ​s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting. Level of EvidenceLevel 5.IRB: Approved under Stanford IRB-56323.

Long term improvement of knee osteoarthritis after injection of single high/very high volume of very pure PRP: A retrospective analysis of patients optimally managed in dedicated centers

IntroductionPRP is gaining increasing interest for pain relief and improvement of joint function in patients with knee osteoarthritis (KOA) but practices and results remain heterogeneous limiting its adoption as standard of care. Current international recommendations are to collect real-life evidence of efficacy with a systematic monitoring of PRP quality and patients' outcomes. We aimed to analyze the response of patients presenting KOA and treated with standardized PRP injection in routine care. We also investigated the potential contributing factors including patient's phenotype and PRP characteristics. MethodsPatients with symptomatic KOA and that failed first-line therapy received a single injection of a qualified PRP prepared using medical devices allowing to recover a high/very high volume of very pure PRP. Visual analogue scale (VAS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded at baseline and during 18 months follow-up. Results431 patients had available follow-up data at 3 months, 291 at 6 months, 137 at 12 months and 44 at 18 months. PRP induced a significant decrease of WOMAC score at all follow up endpoints (29.2 ± 19.2 at 3 months, p < 0.001 and 25.9 ± 19.7 at 12 months, p < 0.01, compared to 39.7 ± 18.9 at baseline). Similar results were observed for pain VAS (38.9 ± 23.3 at 3 months, p < 0.001 and 35.3 ± 24.1 at 12 months, p < 0.05, compared to 56.0 ± 20.7 at baseline). Changes at 12 months were correlated to baseline scores and to the level of improvement at 3 months. The proportion of OMERACT OARSI responders reached 56.2 % for the total cohort and 60.4 % for severe patients at 6 months. Treatment failure occurred for 8.4 % of patients. Age, BMI or Kellgren–Lawrence grade did not impact on efficacy. ConclusionThis real-life study evidences the clinical benefit of a standardized high or very high-volume injection of very pure PRP in patients with KOA, including those with a severe grade. It opens perspectives in the positioning of such strategy to delay arthroplasty and provide insights on factors able to anticipate long term efficacy.

A Nationwide Cross-sectional Survey of Knowledge and Practices of Diabetes Drug Injection Techniques of Patients, Nurses, and Physicians: The China IT Improve Study

ObjectiveTo investigate the knowledge and practices of diabetes drug injection techniques of diabetes patients, nurses, and physicians to support formulating national guidelines for standardized diabetes drug injection techniques. Patients and MethodsIn this nationwide multicenter cross-sectional survey conducted between November and December 2020, patients, nurses, and physicians were randomly chosen from 250 primary, 150 secondary, and 100 tertiary care hospitals using the stratified cluster sampling method. Their knowledge and/or practices of diabetes drug injection techniques were surveyed using the Diabetes Drug Injection Knowledge and Practice Questionnaire for Physicians, Nurses, and Patients. ResultsIn total, 10,694, 2643, and 2816 eligible questionnaires were collected from patients, physicians, and nurses, respectively. Overall, 78.2% (7588/9709) type 2 diabetes patients failed to attain the target hemoglobin A1c. Hypoglycemic episodes and lipohypertrophy occurred in 19.8% and 34.7% of the patients, respectively. Needle reuse (odds ratio, 1.19; 95% CI, 1.07 to 1.33) and incorrect injection site rotation (odds ratio, 1.32; 95% CI, 1.16 to 1.51) were associated with failure to attain the target hemoglobin A1c. Overall, 48.9% physicians and 20.4% nurses had a poor knowledge domain score. Care setting and training, diabetes care experience, and regions were significant determinants of diabetes drug injection knowledge domain scores in both physicians and nurses. ConclusionPoor glycemic control, occurrences of injection-associated complications in diabetes patients, and poor knowledge domain scores of a subset of physicians and nurses highlight the importance of regular assessment and education regarding diabetes drug injection techniques for physicians and nurses and development of national guidelines for diabetes drug injection. Trial RegistrationChictr.org.cn (ChiCTR2100045302).

Evaluation of the efficacy and safety of ultrasound guided injection of carbon nanoparticles as a preoperative localizing tool of non-palpable breast cancer and sentinel lymph nodes detection

Objective This study aimed to measure the efficacy of using carbon nanoparticles in the preoperative localization of early breast cancer (BC) cases as well as in the detection of sentinel lymph nodes in Egypt. In addition, the purpose of the study was to determine whether the efficacy of carbon nanoparticles outweighs their high price and additional shipping fees. Material and methods The current pilot study enrolled 16 early BC patients, particularly those eligible for breast-conserving surgery. All patients underwent standardized injection techniques. The operating surgeons provided comprehensive intraoperative findings and postoperative histopathological reports of the excised tissues. Results After neoadjuvant chemotherapy (NAC), downstaging of the study subjects was achieved until reaching the TNM stage of T1N1M0 and T1N0M0 in 2 cases (12.5%) and 14 cases (87.5%), respectively. Ultrasound-guided injection of carbon nanoparticles was done, followed by surgical excision on the same day or the day after injection. Eleven patients had positive mass lesions preoperatively, with a mean tumoral size of less than 1 cm in maximum dimension. Moreover, 6 out of the 11 patients showed positive black staining intraoperatively with an accuracy of 68.75%. Postoperative histopathological examination (the gold standard) of axillary specimens revealed that 3 out of 16 of the study population have positive tumor-infiltrated lymph nodes. However, only 2 of these cases demonstrated intra-operative black staining, with the black dye’s positive and negative predictive values of staining being 100% and 92.2%, respectively. Conclusions Preoperative carbon nanoparticle suspension injection is a safe and effective method for adequate tumoral localization in BC patients. Nevertheless, this pilot study did not provide strong evidence for the adequacy of sentinel lymph node detection due to the small sample size, high cost, and extra shipping fees of the carbon nanoparticles.

(163) Efficacy of Collagenase Clostridium Histolyticum in Calcified Peyronie’s Disease

Abstract Introduction Peyronie’s disease (PD) affects between 0.4% and 13% of the male population. It leads to inelastic scar tissue in the tunica albuginea which in turn leads to penile curvature, deformity, and shortening. Collagenase clostridium histolyticum (CCH) is the only FDA approved intralesional medication for PD, but its efficacy in calcified PD remains controversial. The two large, double-blind, placebo controlled randomized clinical trials, known as the IMPRESS trials, excluded men with calcified plaques, which occurs in 25-30% of all patients with PD. Objective We aimed to evaluate change in penile curvature in men with calcified PD plaques after 8 injections of CCH in a large cohort of men Methods We prospectively evaluated men with PD presenting to our clinic from October 2018 to November 2020 electing CCH treatment. All men received a pre-treatment penile duplex ultrasound with artificial erection to assess degree of calcification and curvature. We used a grading system to assess calcification: Type 1: The plaque appears as a thickening of the tunica albuginea without acoustic shadowing; Type 2: A moderately calcified plaque with a typical ultrasound shadow, and Type 3: A severely calcified plaque with complete ultrasound shadowing. All men received CCH (0.58 mg) injected directly into the primary plaque at the point of maximal penile curvature using a standardized injection technique following the manufacturer's instructions. Cycles were terminated early if the patient was satisfied with the curvature or subjects reached less than 15 degrees. We remeasured the curvature in patients 4-6 weeks after the final CCH with artificial erection. All results are presented as mean ± standard deviation (SD) Results In total, 60 patents presented with calcified PD plaques with 32 (53.3%) receiving all 8 injections and another 5 patients were satisfied with results and elected to stop treatment. The remaining 23 (38.3%) discontinued before finishing; on average they received 5.6 injections. There were no differences in baseline characteristics between men who completed treatment and those that discontinued. In patients who were satisfied there was significant (p&amp;lt;0.0001) mean change per subject of -21.6 ± 19.9 degrees or 37.3% (Table 1). In the discontinued there was a mean change per subject of -12.8 ± 13.9 degrees (p=0.05). There was no significance difference in change in curvature between grade 2 (-24 ± 14.9 degrees) and grade 3 (-21.3 ± 23.4 degrees) calcified plaques (p=0.71) (Table 1). Conclusions Overall, CCH appears effective in the treatment of patients with calcified PD plaques. In patients who successfully completed 8 injections or was satisfied there was a significant difference in curvature after treatment and can help inform patients about treatment benefits despite calcification. Disclosure Yes, this is sponsored by industry/sponsor: Endo Pharmaceuticals Clarification Industry funding only - investigator initiated and executed study

Epidural Injection Method for Long-Term Pain Management in Rats with Spinal Stenosis.

Epidural injection is one of the most common nonsurgical treatment options for long-term pain relief in lumbar spinal stenosis. Recently, various nerve block injections have been used for pain management. Among them, nerve block through epidural injection is a safe and effective method for the clinical treatment of low back or lower extremity pain. Although the epidural injection method has a long history, the effectiveness of long-term epidural injections in disc diseases has not been scientifically proven. In particular, to verify the safety and efficacy of drugs in preclinical studies, the route and method of drug administration in terms of the clinical application method and duration of use must be established. However, there is no standardized method for long-term epidural injections in a rat model of stenosis to identify the precise efficacy and safety of epidural injections. Therefore, standardizing the epidural injection method is very important for evaluating the efficacy and safety of drugs used for back or lower extremity pain. We describe the first standardized long-term epidural injection method for evaluating the efficacy and safety of drugs according to their route of administration in rats with lumbar spinal stenosis.

Clinical outcomes after lip injection procedures-Comparison of two hyaluronic acid gel fillers with different product properties.

Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods. To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies. In a study sample of 40 subjects, treatment with two soft tissue filler product (HARK or HAJUS ) was randomly assigned. Subjects were injected with 0.5cc per upper and lower lip using a standardized injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post-Day 14 were assessed up to 24 weeks. In subjects treated with HARK , the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HAJUS . Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious. The intensity of early-onset swelling, and other injection-site reactions was lower in subjects treated with HARK than in subjects treated with HAJUS . Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post-Day 14, however, were similar between filler groups.

The Effectiveness and Safety of Botulinum Neurotoxin in Obstetric Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

Obstetric brachial plexus injury, also known as neonatal brachial plexus injury, is not unusual in newborns. Given the lack of a comprehensive synthesis of the available data on the effectiveness of botulinum neurotoxin (BoNT) in treating children with obstetric brachial plexus injury, we conducted a systematic review and meta-analysis. We searched PubMed, Embase, Web of Science, and Cochrane databases from inception to 25 November 2022. Outcomes were function of the shoulder and elbow joints, muscle power of the deltoid, biceps brachii and triceps brachii, and the recurrence rate of subluxation or dislocation after reduction of the shoulder joint after BoNT application. Meta-regression was conducted to assess the moderator effect of age. We included 11 case series and 2 cohort studies. Passive range of motion of shoulder external rotation (standardized mean difference [SMD], 0.678; 95% confidence interval [95%CI], 0.423 to 0.934), Active Movement Scale for shoulder external rotation (SMD, 0.47; 95%CI, 0.131 to 0.808), and active range of motion of elbow extension (SMD, 2.445; 95%CI, 1.556 to 3.334) increased significantly after BoNT. However, the modified Gilbert scale for shoulder abduction (SMD, 1.239; 95% CI, -0.2 to 2.678), the Toronto score for active elbow flexion (SMD, 1.099; 95% CI, -0.053 to 2.252), muscle power of deltoid (SMD, 0.675; 95% CI, -0.599 to 1.949), biceps brachii (SMD, 0.225; 95% CI, -0.633 to 1.083), and triceps brachii (SMD, 1.354; 95% CI, -1.493 to 4.202) did not reach statistical significance. The moderator effect of age was not significant (p = 0.88). Meta-analysis was not done for recurrence rate of subluxation or dislocation due to insufficient data. In conclusion, our data support BoNT use in patients with obstetric brachial plexus injury. However, definite conclusions cannot be drawn due to small sample size and the lack of randomized controlled trials. More research is warranted to clarify the effectiveness of BoNT in patients with obstetric brachial plexus injury by using standardized injection protocols and outcome measurements.

Indocyanine green fluorescence angiography in pediatric intestinal resections: A first prospective mixed methods clinical trial

BackgroundThe aim of this study was to establish the feasibility and safety of the use of indocyanine green technology during pediatric intestinal resections. While indocyanine green fluorescence angiography (ICG-FA) has been advocated as an imaging technique to assess bowel perfusion in adults, few studies have evaluated this technology in a pediatric context. MethodsA prospective clinical trial was conducted. Patients 16 years old or younger undergoing a surgery potentially requiring an intestinal resection were eligible. Patients received a standardized intravenous injection of indocyanine green and intestinal perfusion was evaluated. The study endpoints included safety, impact on bowel resection and feasibility and acceptance of ICG-FA in this population. ResultsFrom May 2020 to March 2021, 30 consecutive patients were included in this trial. Final analysis was done on 28 patients with a median age of 15.00 [6.36,85.00] weeks and weight of 5.58 [3.64,11.70] kg at surgery. Adequate fluorescence was achieved in less than one minute for all cases with an average dose of 0.14 mg/kg. No adverse event related to indocyanine green occurred. ICG-FA versus standard assessment of potential resection sites differed in 62% (95% IC 0.41–0.82) of our cases. Qualitative analysis demonstrated that 95% of the surgical team agreed that ICG-FA was safe. ConclusionsThe use of ICG-FA is feasible and safe for pediatric intestinal resections. Introduction of ICG-FA was simple and acceptance rates were high within the surgical team. This fluorescence imaging may be a valuable imaging technology for intestinal resections in pediatric surgery.

10.18081/2333-5106/2022.10/136

Autism spectrum disorder (ASD) is a group of neurodevelopmental disorders characterized by social deficits, communication inabilities and stereotypic behaviors. There are many suspected genetic causes of autism, but no cure has been proven to work to treat the disorder. Stem cells have been studied for their potential role in treating ASDs. Twenty-five children who fulfilled the autism criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [total scores below 30 indicate that an individual is “non-autistic,” while scores of 30 or above indicate that an individual is “autistic.” Individuals with scores above 30 are further subdivided into having “mild to moderate autism” (30 to 36.5) or “severe autism” (37 to 60)]. In this study only Childhood Autism Rating Scale (CARS) scores &gt;37 was participated in this study. Harvested bone marrow from posterior iliac crest under light general anesthesia, for all patients under 10 kg collected 6 ml/kg while calculated the volume above 10-year age group (60 ml + [body weight in kg − 10] × 7 ml). Isolated mononuclear cells through Ficoll gradient under sterile condition in laminar flow class 2. The end products transmitted to sterile tube and injected slowly intrathecally. The same procedure was repeated 3 months later. The result after first bone marrow transplant showed that no severe side effects related with these procedures. The median CARS score decreasing from 52 to 44.2 (P =0.02). Beside this data the severity of autism spectrum disorder signs and symptoms were reduced. Inconclusion, this resulted data suggested that stem cell therapy for children with autism might be safe and effective. However, the evidence was compromised by the limitations in current study size, lacking standardized injection routes and doses of stem cells, as well as shortages in diagnostic tools and long period follow-up studies.

Strategies for selecting perforator vessels for transverse and oblique DIEP flap in male pediatric patients: Anatomical study and clinical applications.

BackgroundTransverse and oblique deep inferior epigastric artery perforator (DIEP) flaps are widely used in breast, lower extremity, urogenital, head and neck reconstruction. In this report, we present our experience with selecting perforator vessels for transverse and oblique DIEP flaps based on an anatomical study and clinical cases.Materials and methodsA detailed anatomical study of the DIEP flap was carried out using a standardized injection of lead oxide in 10 fresh cadavers. Additionally, 35 male pediatric patients (age 5–12 years) underwent lower extremity reconstruction with a DIEP flap. A transverse DIEP flap was used when the defect template did not exceed zone IV, while an oblique DIEP flap was used when the defect template exceeded zone IV.ResultsPerforators located below the umbilicus in zones I and II were rich in transverse anastomoses across the midline of the abdominal wall, which is the basis for the transverse DIEP flap. Perforators lateral to the umbilicus in zone I had true anastomoses with the musculophrenic artery, the morphological basis for the oblique DIEP flap. The DIEP flap design was transverse in 20 patients and oblique in 15. Flap sizes ranged from 8 × 4.5 cm2 to 24 × 9 cm2. One oblique DIEP flap was necrosed totally, and it was repaired by a latissimus dorsi musculocutaneous flap.ConclusionThe transverse DIEP flap design based on the perforator located below the umbilicus in zone I is recommended for small skin and soft tissue defects. We recommend the use of the oblique DIEP flap design based on the perforator lateral to the umbilicus in zone I as an extended flap to reconstruct large tissue defects.

The importance of standardized periorbital steroid injections for thyroid-associated ophthalmopathy

Thyroid-associated ophthalmopathy (TAO) is now the most prevalent orbital disease in adults, with a complex pathophysiology and a wide range of clinical symptoms. In recent years, significant progress has been made in the research on the treatment of TAO. Periorbital steroid injections are considered a precise local treatment and can improve ocular symptoms with minor side effects. However, there is no standardized orbital injection protocol in China, resulting in increased complications. Therefore, it is essential to standardize periorbital steroid injections in treating TAO.

815-P: A Nationwide Cross-Sectional Survey of Knowledge and Practices of Diabetes Drug Injection Techniques of Patients, Nurses, and Physicians: The China IT Improve Study

Introduction: This survey studied the knowledge and/or practices of drug injection techniques of diabetes patients, nurses, and physicians to guide formulating national standardized diabetes drug injection guidelines. Methods: Patients, nurses, and physicians were recruited from 259 primary, 150 secondary, and 100 tertiary care hospitals chosen using stratified cluster sampling. Their knowledge and/or practices of drug injection techniques were surveyed using the Diabetes Drug Injection Knowledge and Practice Questionnaire for Physicians, Nurses and Patients. Results: Totally 10694, 2643 and 2816 eligible questionnaires were collected from diabetes patients (92.3% type 2 diabetes) , physicians and nurses, respectively. Needlestick injury occurred in 13.0% patients, 19.8% patients had hypoglycemic episodes and 54.5% patients failed to attain the target HbA1c. Care setting and injection practice were significant determinants of needlestick injury, hypoglycemia and target HbA1c attainment. Overall, 48.9% physicians and 20.4% nurses had a poor knowledge domain score. Care setting, training, and diabetes care experience were significant determinants of diabetes drug injection knowledge domain scores in both physicians and nurses. Furthermore, &amp;gt;92% of the nurses properly performed the steps of injecting diabetes drugs. Needle injury occurred in 24.0% nurses. Care setting, nurse professional levels, and diabetes care experience were significant determinants of needlestick injury. Conclusions: This nationwide survey offers insights into diabetes drug injection knowledge and practices in China and provides evidence for drafting nationwide guidelines for diabetes drug injection techniques. Disclosure L.Guo: None. Q.Ji: None. S.Jiang: None. D.Liu: None. J.Liu: None. X.Ran: None. Y.Xue: None. Q.Zhang: None.

Botulinum toxin type A for the treatment of excessive gingival display – A systematic review

Gummy smile has traditionally been treated with invasive or demanding surgical and orthodontic techniques. Several studies have shown that targeted injection of the upper lip elevator muscles with botulinum toxin is an effective treatment for this condition. However, no standardized injection protocol with reproducible results has yet been published.A systematic review of the literature has been performed using Medline, Scopus, and Embase. All articles relevant to the research question were analyzed.After removing duplicates, 162 articles were selected, of which 9 were included in the analysis after applying exclusion and inclusion criteria, for a total of 269 patients. Onabotulinum toxin type A (ONA-BoNTA) was used in 7 studies and abobotulinum toxin type A (ABO- BoNTA) in 2 studies, at various dilutions. The number of sites injected varied from 1 to 3 per side, with variable targeting of the Levator labii superioris alaeque nasalis, Levator labii superioris, Zygomaticus minor, Zygomaticus major and Orbicularis oris. The dose used per side varied from 1.25 to 6 U of ONA-BoNTA and from 2.5 to 7.5 U of ABO- BoNTA. The injection protocol was tailored to the type of gingival smile in one study only, another study compared results of targeting two different muscles, and one study evaluated different dosages of toxin for the same injection site. The average improvement ranged from 24.85% to 99.65% and the effect persisted from 12 to 36 weeks. Very good patient satisfaction was reported in 6 studies. Fourteen adverse events were reported, all of them mild and transient.The treatment of gummy smile by botulinum toxin injection is effective, safe, rapid, minimally invasive and reversible. Protocols vary widely in the literature and no standardized procedure emerges. A patient-specific approach, adapted to their anatomy, type of gummy smile and the severity of the exposure seems to be the most appropriate. Randomized controlled studies are needed to make this approach more systematic.

"State of the Mewnion": Practices of Feral Cat Care and Advocacy Organizations in the United States.

Over the last several decades, feral cats have moved from the fringes to the mainstream in animal welfare and sheltering. Although many best practice guidelines have been published by national non-profits and veterinary bodies, little is known about how groups “in the trenches” actually operate. Our study sought to address that gap through an online survey of feral cat care and advocacy organizations based in the United States. Advertised as “The State of the Mewnion,” its topics included a range of issues spanning non-profit administration, public health, caretaking and trapping, adoptions of friendly kittens and cats, veterinary medical procedures and policies, data collection and program efficacy metrics, research engagement and interest, and relationships with wildlife advocates and animal control agencies. Respondents from 567 organizations participated, making this the largest and most comprehensive study on this topic to date. Respondents came primarily from grassroots organizations. A majority reported no paid employees (74.6%), served 499 or fewer feral cats per year (75.0%), engaged between 1 and 9 active volunteers (54.9%), and did not operate a brick and mortar facility (63.7%). Some of our findings demonstrate a shared community of practice, including the common use of a minimum weight of 2.0 pounds for spay/neuter eligibility, left side ear tip removals to indicate sterilization, recovery holding times after surgery commonly reported as 1 night for male cats and 1 or 2 nights for females, requiring or recommending to adopters of socialized kittens/cats that they be kept indoor-only, and less than a quarter still engaging in routine testing of cats for FIV and FeLV. Our survey also reveals areas for improvement, such as most organizations lacking a declared goal with a measurable value and a time frame, only sometimes scanning cats for microchips, and about a third not using a standardized injection site for vaccines. This study paints the clearest picture yet available of what constitutes the standard practices of organizations serving feral and community cats in the United States.

A Novel Injection Technique to the Lateral Pterygoid Muscle for Temporomandibular Disorders: A Cadaveric Study.

Lateral pterygoid muscle activity is associated with the pathological mechanisms of some temporomandibular disorders. The authors aimed to define and demonstrate a novel, practical, and safe technique for botulinum toxin type A injection to the lateral pterygoid muscle based on their findings. Their secondary aims were to standardize the injection pattern according to the variations of the lateral pterygoid muscle and its surrounding anatomical structures, and to establish its advantages over intraoral injection. Twenty cadaver heads were dissected. The lateral pterygoid muscle and its surrounding structures were investigated for anatomical variations. Based on these findings, a standardized extraoral injection protocol was defined and compared with the intraoral technique for accuracy and safety. The average depth of the lateral pterygoid plate from the skin surface was 49.9 ± 2.2 mm, and the mean width of the lateral pterygoid plate was 10.5 ± 3.9 mm. The extraoral injection approach based on the location of the maxillary tuberosity, tragus, and lateral pterygoid plate was consistent in all dissections for the accuracy of the intramuscular injection. In the intraoral approach, standardization of the entry point of the needle through the oral mucosa is difficult, which makes adjustment of the depth of the injection challenging while increasing the risk of neurovascular injury. The clinical significance of the lateral pterygoid muscle makes it worthwhile to implement minimally invasive treatments before considering more invasive options. The authors define a safe, accurate, and reliable approach with ease of administration in patients with temporomandibular disorders.