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PubMed2003

Intracordal injection of autologous fat in patients with unilateral laryngeal nerve paralysis: long-term results from the patient's perspective.

OBJECTIVE: Based on 80 patients with a previously nonsurgically treated unilateral laryngeal nerve paralysis (ULNP) and according to the patient's self-assessment, the authors document the long-term results achieved with the intracordal injection of autologous fat. STUDY DESIGN: Retrospective series, inception cohort. METHODS: Kaplan-Meier actuarial life table method and univariate analysis. RESULTS: None of the 80 patients died in the immediate postoperative period. Morbidity included hematoma at the donor site (in three patients), development of an intracordal cyst at the injection site (in three patients), fat extrusion at the injection site (in one patient), and temporary tracheotomy (in one patient). The initial and ultimate overall success rates were 96.2% and 77.2%, respectively. In univariate analysis, none of the variables under analysis (gender, age, associated neurological lesions, associated pneumonectomy, associated neoplasia, cause of the ULNP, side of the ULNP, nerve involved, delay between the onset of the ULNP and the intracordal injection, severity of the symptoms, mode of harvesting the autologous fat, and surgeon who performed the injection) was statistically related to the ultimate outcome after the intracordal injection of autologous fat. Among the group of 45 patients in whom the intracordal injection was initially considered to be successful with no further recovery of motion of the true vocal cord and a minimum survival of 12 months, the ultimate overall success rate was 62.2%, and the 3-month, 6-month, and 12-month Kaplan-Meier actuarial estimates for success were 91.1%, 72.8%, and 63.1%, respectively. CONCLUSIONS: In the present study, data confirm that the intracordal injection of autologous fat is a useful and safe procedure in patients with ULNP. However, the impossibility of exactly predicting the amount of resorption of the injected fat and the lack of predictability of the duration of the results, together with the good and stable results achieved at the authors' department with the medialization thyroplasty led the authors to reduce its current use.

Adipose Tissue↗
PubMed2003

Volume analysis of preadipocyte injection for vocal cord medialization.

OBJECTIVE: To compare the volume retention of injected preadipocytes with that of standard fat injection in a paralyzed rabbit true vocal cord. STUDY DESIGN: Prospective analysis with blinded data collection. METHODS: Thirteen New Zealand white rabbits were divided into two groups. Group 1 consisted of seven animals undergoing left-side vocal cord paralysis by resection of a 1-cm segment of the left-side recurrent laryngeal nerve and abdominal fat harvest for isolation of preadipocytes. Preadipocytes were cultured under sterile conditions in cell culture media. Animals in group 2 also underwent left-side vocal cord paralysis without fat harvest. After 10 to 14 days, in a second procedure, group 1 underwent injection of 0.1 mL cultured autologous preadipocytes, and group 2 underwent routine injection of 0.1 mL abdominal fat harvested during the same procedure. At 6 and 12 months, volumetric analysis was performed. RESULTS: Volume analysis at 6 months showed a mean volume of 0.029 mL retained fat in group 2 representing a retention of approximately 29% (SD = 0.023) of the original injected volume. Retention in group 1 animals approximated 0.002 mL (SD = 0.0024) or 2% of the injected volume. Analysis at 12 months showed a mean volume of 0.008 mL (SD = 0.0078) in group 2 and of 0.002 mL (SD = 0.0015) in group 1. Group 2 showed significantly higher volumes of the injected fat at 6 and 12 months (P <.033). CONCLUSION: Volumes obtained with standard fat injection were superior to those obtained with preadipocyte injection at both 6 and 12 months.

Adipocytes↗
PubMed1997

Apparent failure of one injection of benzathine penicillin G for syphilis during pregnancy in human immunodeficiency virus-seronegative African women.

BACKGROUND: Syphilis remains a major cause of premature birth, fetal and perinatal death, and congenital syphilis in South Africa, despite systematic antenatal screening by rapid plasma reagin and treatment with 2.4 million U of benzathine penicillin G. GOAL: To determine whether one injection of 2.4 million of U of benzathine penicillin G, as recommended by the 1993 Centers for Disease Control and Prevention guidelines, is sufficient treatment for early syphilis during pregnancy. STUDY DESIGN: Outcome of pregnancy was prospectively analyzed after zero to three weekly intramuscular injections of benzathine penicillin G in 180 of 212 human immunodeficiency virus-seronegative black urban women with syphilis in Pretoria, South Africa. RESULTS: One hundred eight women receiving two or three weekly intra-gluteal injections of benzathine penicillin G had a favorable pregnancy outcome. However, after only one injection, lower birth weight, increased immaturity, prematurity, and total preterm birth rate resulted. Total pregnancy loss and perinatal mortality were also increased. After exclusion of patients treated with oral penicillin derivatives and adjustment for the estimated duration of treponemicidal levels at 3 weeks after injection, the perinatal outcome was reanalyzed. Treponemicidal coverage of 3 weeks or less resulted in decreased birth weight (2,748 vs. 3,130 g, P = 0.004) compared with treponemicidal coverage lasting longer than 3 weeks. In addition, the relative risks for prematurity (relative risk [RR], 8.5; 95% confidence interval [CI95], 2.5-28), perinatal mortality (RR, 20.5; CI95, 2.3-184), and congenital syphilis (RR 2.0; CI95-0.6-6.8) were increased when coverage was less then 3 weeks. These results were comparable to those obtained when no treatment was given. Most of the incompletely treated women delivered at less than 4 weeks after they received their injection. These also had the worst neonatal outcome. Impaired outcome due to short treatment clustered in early attenders of prenatal care (before the 28th week of gestation) and when the initial rapid plasma reagin titer was higher than 16. Although numbers were small for a firm conclusion, incompletely treated and untreated women who had taken intercurrent oral ampicillin had an improved birth weight, lower prematurity rate, and lower fetal rate. CONCLUSIONS: One intramuscular injection of 2.4 million U benzathine penicillin G or treponemicidal concentrations lasting 3 weeks or less is not sufficient therapy for pregnant women with syphilis. Although fetal outcome is clearly improved at birth with more than one injection, without follow-up of the neonates, complete cure cannot be predicted from these data. To obtain treponemicidal activity for longer than 3 weeks, the authors recommend administration of two injections of 2.4 million U benzathine penicillin at least 1 week apart, if possible at 4 weeks or more before delivery. This therapy is especially important for patients who attend prenatal care before 28 weeks of pregnancy or when the rapid plasma reagin titer is higher than 16.

Adult↗
PubMed2002

Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study.

STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

Adult↗
PubMed1997

Donor-specific tolerance by perioperative intrathymic injection of bone marrow cells in the rat cardiac allograft model: use of FK506 can shorten the necessary duration of pretransplant intrathymic conditioning.

BACKGROUND: Many strategies of tolerance induction by intrathymic (IT) injection of donor alloantigens have been reported to date; however, the timing of IT injection is usually 1-3 weeks before transplantation. METHODS: To apply IT injection to cadaveric organ transplantation, 1 x 10(8) fully allogeneic bone marrow cells (BMC) of Buffalo (BUF; RT1b) rats were intrathymically injected into Wistar Furth (WF; RT1u) rats at the time of BUF cardiac allografting with short-course therapy of antilymphocyte serum (ALS) and FK506 in our experimental model. RESULTS: Allogeneic IT injection of BUF BMC with ALS and FK506 indefinitely prolonged graft survival (mean survival time > 210 days) in all WF rats. On day 130 after grafting, tolerant WF rats accepted donor BUF skin grafts (> 120 days) but not third-party Lewis skin grafts. In control groups, syngeneic IT injection of WF BMC or intravenous injection of donor BUF BMC in combination with ALS/FK506 therapy failed to induce tolerance. In vivo testing was performed during induction (1 month) or during maintenance (6 months of tolerance. In the mixed lymphocyte reaction (MLR), spleen T cells of tolerant rats at 1 month after grafting displayed hyporesponsiveness after stimulation with donor cells. The addition of interleukin (IL)-2 to MLR culture did not restore T-cell responsiveness. Tolerant rats had a significantly decreased frequency of T cytotoxic cell precursors (fTcp) of 1:4,926, and frequency of IL-2-producing T helper cell precursors (fThp) of 1:23,925, compared with naive rats (1: 2,158 and 1:4,266, respectively). By 6 months after grafting, however, the anti-donor MLR proliferative responses of tolerant rats had been restored to the levels of naive splenic T cells. These tolerant rats displayed restoration of the (fTcp) of 1:2,842 and of the (fThp) of 1:5,630, which were comparable frequencies of naive rats. Suppressor T cells did not contribute in this model. In cardiac grafts of tolerant rats induced by IT injection, expression of both Th1 (interferon-gamma and IL-2) and Th2 (IL-4 and IL-10) cytokines was detected in the early phase; thereafter, expression was completely inhibited, except for interferon-gamma in the chronic phase. CONCLUSIONS: Perfect donor-specific tolerance was obtained by IT injection of donor BMC at the time of transplantation, while alloimmune responses were maintained at levels similar to those of naive rats.

Adoptive Transfer↗
PubMed2006

Low molecular weight heparin self-injection training: assessment of feasibility, tolerance and economic analysis in emergency departments.

BACKGROUND: The purpose of this study was to assess low molecular weight heparin auto-injection skills of self-supporting patients, taught by a nurse through a rapid demonstration in an emergency department. METHODS: The study was a prospective, multicentre study, carried out in emergency departments. It included all ambulatory attending patients over 18 years of age, who were given a lower limb cast in an emergency ward and provided with limited orthopaedic treatment. Eligible patients who accepted self-injection training were given a quick demonstration by the nurse in the emergency ward. A questionnaire about the perception of the patient was completed at the beginning of the treatment and at the end of the treatment. A surveillance chart for recording injections and side effects was also given to the patient, and platelet counts were performed twice weekly. FINDINGS: Two hundred and fourteen patients have been assessed. Forty-four patients (20.5%) were judged inappropriate for training (n=19) or refused it (n=25). Primary perception of the self-injection method showed absence of fear of injections among patients in 43.7% of cases. Training was successful in 88% of cases. Twenty-one patients out of 170 (12%) gave up after completing the training. Questionnaires given at the end of the treatment found a generally favourable opinion on self-injections among 73.26% of patients (n=86). Compliance was good - 95.5% of patients completed all their injections. Platelet counts were considered appropriate only in 52.5% of cases. INTERPRETATION: It seems possible to extend the practice of self-injection to other types of injections prescribed after discharge from the emergency department, such as preventive low molecular weight heparin for surgical or medical purposes and curative ambulatory low molecular weight heparin treatment for deep vein thrombosis.

Adult↗
PubMed2006

Recent intraarticular steroid injection may increase infection rates in primary THA.

We retrospectively determined the rate of therapeutic intraarticular steroid injection within 1 year before total hip arthroplasty (THA) for osteoarthritis and whether the injection of the steroid increased the risk of infection. In a retrospective matched cohort study, 224 primary THAs (217 patients) implanted within 1 year of intraarticular steroid injection (Group 1) were compared with 224 primary THAs (220 patients) in patients who had not received an injection (Group 2). The mean time between injection and THA was 112 days (SD, 81 days). In Group 1, there were three deep and 11 superficial infections compared with one deep and eight superficial infections in Group 2. The hazard ratios of deep and superficial infections were 3 (95% CI, 0.3, 29.8) and 1.5 (95% CI, 0.6, 3.6), respectively. Intraarticular steroid injection within 1 year of THA did not affect postoperative rates of infection. However, the mean time from steroid injection to THA was 44 days (SD, 23 days) in the few patients who had deep infection develop. While not statistically significant, this raises a concern of increased risk of deep infection when receiving a steroid injection within 6 weeks of THA. Caution should be used before giving an intraarticular steroid injection within 2 months before THA.

Adult↗
PubMed2005

Effect of vertebral shell on injection pressure and intravertebral pressure in vertebroplasty.

STUDY DESIGN: An experimental biomechanical study conducted on osteoporotic cadaveric vertebrae. OBJECTIVES: 1) To measure the intravertebral shell pressure and injection pressure; and 2) to determine the effect of the vertebral shell on the intravertebral shell pressure and on the injection pressure. SUMMARY OF BACKGROUND DATA: Forces that govern cement flow are an essential component of the cement injection process in vertebroplasty. The vertebral shell may play a significant role in confining the flow of cement in the vertebral body and thereby affecting the intravertebral pressure and injection pressure. METHODS: A small fenestration was created in the left lateral vertebral shell of 14 vertebrae. A valve to open and close the fenestration and a sensor to measure the intravertebral pressure were attached to the opening. A closed fenestration simulated an intact shell, whereas an open fenestration represented a vented shell. Injection pressure and intravertebral pressure at the shell were recorded during a controlled injection. RESULTS: A closed fenestration resulted in a significant increase in the intravertebral pressure at the shell. During the injection, the shell pressure increased on average to approximately 3.54 +/- 2.91 kPa. Conversely, an open fenestration resulted in an instant relaxation of the shell pressure to the ambient pressure of 0 kPa. Additionally, the injection pressure was approximately 97 times higher than the shell pressure. CONCLUSION: The presence of vertebral shell seems to be important for intravertebral pressure. However, the intravertebral shell pressure adds very little to the injection pressure.

Biomechanical Phenomena↗
PubMed2006

Ex vivo experiments of a new injection cannula for vertebroplasty.

STUDY DESIGN: An experimental study using cadaveric vertebrae. OBJECTIVES: To measure the injection pressure in an ex vivo model and determine whether the redesigned cannula, featuring 2 distinct sections of different diameters, significantly reduces the injection pressure. SUMMARY OF BACKGROUND DATA: An important limitation of vertebroplasty is the excessive pressure required to inject sufficient cement. The redesigned cannula accounts for the "bottleneck" of the injection previously identified. It has a distal section that is adapted to the pedicles and a proximal section with a larger diameter. METHODS: Two cannulas were tested, a conventional 8-gauge and the redesigned cannula. There were 3 mL of cement injected in small strokes of 0.75 mL into the left and right hemivertebrae. A custom-made injection device monitored the injection pressure and cement volume. RESULTS: Average injection pressure was 2.3 MPa, often approaching the human physical limit and resulting in insufficient filling. The average pressure of the redesigned cannula was 44% lower than that of the conventional cannula, a highly significant result (P < 0.001). CONCLUSION: The new cannula may improve vertebroplasty by significantly easing cement injection. It is cost effective and can be easily integrated into the existing procedure.

Arthroplasty↗
PubMed2006

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients.

OBJECTIVE: To determine whether treatment with corticosteroids decreases the incidence of postextubation airway obstruction in an adult intensive care unit. DESIGN: Clinical experiment. SETTING: Adult medical and surgical intensive care unit of a teaching hospital. PATIENTS: One hundred twenty-eight patients who were intubated for >24 hrs with a cuff leak volume <24% of tidal volume and met weaning criteria. INTERVENTIONS: : Patients were randomized into a placebo group (control, n = 43) receiving four injections of normal saline every 6 hrs, a 4INJ group (n = 42) receiving four injections of methylprednisolone sodium succinate, or a 1INJ group (n = 42) receiving one injection of the corticosteroid followed by three injections of normal saline. Cuff volume was assessed 1 hr after each injection, and extubation was performed 1 hr after the last injection. Postextubation stridor was confirmed by examination using bronchoscopy or laryngoscopy. MEASUREMENTS AND MAIN RESULTS: The incidences of postextubation stridor were lower both in the 1INJ and the 4INJ groups than in the control group (11.6% and 7.1% vs. 30.2%, both p < .05), whereas there was no difference between the two treated groups (p = .46). The cuff leak volume increased after the second and fourth injection in the 4INJ group and after a second injection in the 1INJ group compared with the control group (both p < .05). CONCLUSIONS: A reduced cuff leak volume is a reliable indicator to identify patients at high risk to develop stridor. Treatment with a single or multiple injections of methylprednisolone can effectively reduce the occurrence of postextubation stridor.

Aged↗
PubMed2004

Prostatic tissue ablation by injection: a literature review.

PURPOSE: Most men 50 to 80 years old will have development of some degree of benign prostatic hyperplasia (BPH). Many who experience lower urinary tract symptoms (LUTS) will be treated medically. However, significant numbers will have more severe and progressive disease requiring surgery. Transurethral resection of the prostate is the current gold standard of treatment for BPH. Minimally invasive therapies for symptomatic BPH emerge and fade continuously. However, intraprostatic injection for BPH has been used for more than 100 years and may be on the verge of a rebirth. The goal of this review is to familiarize the reader with the origins and history of intraprostatic injection, and its evolution using transperineal, transrectal and transurethral routes with multiple injectants. Initially used to treat urinary retention in men with BPH, its primary indication is now for LUTS. MATERIALS AND METHODS: We performed a structured MEDLINE review of the literature on intraprostatic injections from 1966 to 2003, augmented with relevant articles from select journals and documents dating to 1832. RESULTS: In patients with BPH transperineal and transurethral injections have the most systematic evaluation. Most injectants will cause localized prostatic necrosis and gland volume reduction with varying degrees of LUTS relief. Anhydrous ethanol is the most widely studied injectable to date. There are advantages and disadvantages associated with each route of injection. CONCLUSIONS: Examined for more than a century, the potential for using injectables for prostatic tissue ablation remains significant. More systematic laboratory research and clinical trials, currently ongoing, need to be completed.

Animals↗
PubMed2006

Steroid injections in the management of trigger fingers.

OBJECTIVES: The most commonly used primary treatment for trigger fingers is corticosteroid injection in the flexor tendon sheath, followed by surgical release if unsuccessful. This study examines the surgical and nonsurgical treatment of patients with trigger fingers presenting to a large Canadian tertiary referral center. The treatment success and side-effect profile of steroid injection therapy and surgical release were examined in the context of comorbid illness, specifically, diabetes mellitus. DESIGN: Retrospective review of all patients with trigger finger who were seen by the senior authors between January 1999 and June 2004. RESULTS: In the study period, 118 trigger digits were treated. This study included 92 nondiabetic, 21 type 2 diabetic, and five type 1 diabetic trigger fingers. Of the 89 digits that received at least one steroid injection, 46 (52%) resolved completely and 42 (47%) were improved. Nondiabetic digits were treated successfully in 40 out of 70 digits (57%) with steroid injection therapy. Diabetic patients had a success rate of 6 of 19 (32%) with steroid injections, which is significantly lower than nondiabetics (P = 0.04). All type 1 diabetics (n = 5) required surgical treatment. Surgical treatment was successful in 71 of 72 (99%) digits. No side effects of steroid injection were noted, and short-term postoperative side effects were noted in 26 of 72 surgical patients (36%). No statistically significant differences were found in surgical complication rates in diabetics vs. nondiabetics or type 1 diabetics vs. type 2 diabetics. CONCLUSIONS: Steroid injection therapy should be the first-line treatment of trigger fingers in nondiabetic patients. In diabetics, the success rate of steroid injection is significantly lower. Injection therapy for type 1 diabetics was ineffective in this study. Surgical release of the first annular (A1) pulley is most effective overall in diabetics and nondiabetics alike, with no higher rates of surgical complications in diabetics.

Adult↗
PubMed2005

Enhancement of perineurial repair and inhibition of nerve adhesion by viscous injectable pure alginate sol.

BACKGROUND: Clinical treatment of recurrent symptoms following peripheral nerve decompression is problematic. Removal of scar tissue can produce an inappropriately pronounced healing response and thereby lead to more serious tethering or compression of the nerve. The goal of the present study was to test the ability of viscous injectable pure alginate sol to prevent perineurial adhesion using a rat neurolysis model. METHODS: The antiadhesive effect of viscous injectable pure alginate sol after neurolysis was evaluated histologically and biomechanically. A total of 40 rats were used in this study. The viscous injectable pure alginate sol was applied topically on the right side after external (six rats) or extensive internal (six rats) neurolysis, whereas the left side received no treatment. The nerves were harvested over 6 weeks, and histologic analysis was performed with hematoxylin and eosin staining and Masson trichrome staining. Functional analysis of the blood and perineurial barriers was also evaluated with Evans blue albumin (four rats). Sixteen rats were used for biomechanical analysis, and eight rats were used as a control group. The results were analyzed statistically using a post hoc test. RESULTS: Histologic examination showed that the use of viscous injectable pure alginate sol was associated with excellent biocompatibility and strong inhibition of perineurial granulation. Viscous injectable pure alginate sol was absorbed completely within 6 weeks without inducing inflammation. In addition, viscous injectable pure alginate sol enhanced repair of the perineurium associated with regeneration of epithelial-like cell layers, a key structure necessary for barrier function of the inner layer of the perineurium. Functional analysis with Evans blue albumin clearly demonstrated that, although blood nerve barrier function recovered by 6 weeks postoperatively in all nerves, the perineurial barrier function recovered only in the sol-treated nerves. Biomechanical study showed a significant antiadhesive effect of viscous injectable pure alginate sol. CONCLUSIONS: Viscous injectable pure alginate sol inhibited adhesion formation around nerves and enhanced regeneration of the perineurium with barrier function. Because excessive perineurial fibrosis and tethering at the neurolysis or neurorrhaphy site is a common postoperative problem in peripheral nerve surgery, viscous injectable pure alginate sol appears to have potentially broad clinical applications.

Alginates↗
PubMed2004

Contrast-enhanced magnetic resonance angiography of the carotid arteries: influence of injection rates and volumes on arterial-venous transit time.

RATIONALE AND OBJECTIVES: To assess the influence of injection rates and volumes on the arrival time of contrast material (CM) in the common carotid artery, the jugular vein and the resulting arterial-venous transit time. Additionally the relationship between injection parameters and the extent of a CM plateau was evaluated. MATERIALS AND METHODS: In 60 patients a CM injection was necessary to investigate suspected cranial disease. All patients were prospectively assigned to 6 protocol groups with varying volumes of gadolinium dimeglumine (2, 10, 20 mL) and injection rates (0.5, 1, 2, 4 mL/s). Simultaneously to the CM injection, 50 repetitive transverse measurements (1/s) were acquired at the level of the common carotid artery. Based on the resulting signal-time curves, the arrival time of the contrast material in the common carotid artery and the jugular vein, the resulting arterial-venous transit time, the peak enhancement and the extent of a CM-plateau were calculated as a function of the injection parameters. RESULTS: Smaller flow rates (0.5 mL/s) resulted in a longer arrival time in the common carotid artery (mean value 22,6 seconds +/- 2.3) and the jugular vein (mean value 32.6 seconds +/- 2.6) and resulted in longer arterial-venous transit time (mean value 10.1 second +/- 1.9). The volume showed no effect on these parameters. The peak arterial and venous signal intensity and a consistent CM-plateau after 50 seconds were dependent on the volume, but not on the injection rate. CONCLUSION: The injection rate showed an influence to the arrival time in the common carotid artery and the jugular vein and also to the arterial-venous transit time. The injected volume only affected the extent of the contrast plateau. A flow rate of 1 to 2 mL/s and a minimum of 20 mL gadolinium dimeglumine are recommended to achieve optimal image quality without venous overlay.

Adolescent↗
PubMed2006

Managing self-injection difficulties in patients with relapsing-remitting multiple sclerosis.

Difficulties with self-injection, including inabillity to self-inject, are common for individuals taking home-administered injectable medications. In relapsing-remitting multiple sclerosis (MS), all of the currently available disease-modifying medications are injectables marketed for self-injection. Problems with self-injection pose a barrier to treatment adherence for many patients. Clinicians at the University of California, San Francisco (UCSF) Multiple Sclerosis Center have developed a number of strategies to help patients who experience anxiety associated with self-injection. These strategies have been empirically tested and found to be effective and easily implemented by mental health professionals and nurses. This article offers case examples and discussion of the principles of the techniques developed at UCSF to remediate patients' difficulties with self-injection. Nurses are most often the healthcare providers responsible for training MS patients in self-injection and monitoring their compliance. Nurses who are familiar with these tools have the opportunity to have a significant positive impact on patient comfort, confidence, and, ultimately, successful long-term adherence to disease-modifying medications.

Anxiety↗
PubMed2006

Efficacy of EMLA cream to reduce fear and pain associated with interferon beta-1a injection in patients with multiple sclerosis.

Fear of pain from injections may affect adherence to needed drug therapy. A single-blind, placebo-controlled crossover study was conducted to evaluate the efficacy of EMLA cream in reducing the fear and pain associated with intramuscular (IM) injection during administration of interferon beta-1a to patients with multiple sclerosis. Patients rated fear of injection on a visual analog scale before the injection and rated injection pain following the injection. With the application of EMLA cream, the mean pain-of-injection score was found to be significantly lower than the mean fear-of-injection score. The 18 patients who completed the study experienced a statistically significant decrease in both scores. This study suggests that the use of EMLA cream may reduce the pain and fear associated with IM injections.

Adjuvants, Immunologic↗
PubMed2006

Multiple interleukin-18 injections promote both mouse Th1 and Th2 responses after sublethal Escherichia coli infection.

Interleukin (IL)-18 is considered to induce exclusively the Th1 immune response but not the Th2 response in the presence of adequate IL-12 stimulation in bacterial infections. However, we demonstrate herein that multiple IL-18 injections to the mice not only enhance the early Th1 response but also stimulate the Th2 response later after viable Escherichia coli infection. Multiple IL-18 injections (three alternate-day injections) raised the serum interferon (IFN)-gamma level at 6 h and serum Th2 cytokine levels, such as IL-4, IL-10 and IL-13, at 48 h after infection, while a single IL-18 injection increased only the serum IFN-gamma level. Depletion of mouse CD4+ cells suppressed the IL-18-induced Th2 cytokines, IL-4, IL-10 and IL-13. In contrast, depletion of natural killer (NK)1.1+ cells reduced the IFN-gamma and IL-13 levels. Moreover, multiple IL-18 injections up-regulated the serum IgM level at 72 h after infection while a single IL-18 injection did not. Interestingly, neutralization of IL-4 but not IFN-gamma partially suppressed the increased serum IgM. Liver mononuclear cells (MNCs) from the mice treated with multiple IL-18 injections significantly increased more production of not only IFN-gamma but also Th2 cytokines and IgM by in vitro lipopolysaccharide (LPS) stimulation than those from the phosphate-buffered saline (PBS)-treated mice, while liver MNCs from the single IL-18-injected mice also increased IFN-gamma production but significantly suppressed IL-4 and IgM production compared to those from the PBS-treated mice. Our findings suggest that multiple injections of IL-18 up-regulate both the cellular and humoral innate immunities, thereby enhancing host defence against bacterial infections.

Animals↗
PubMed1994

Pharmacokinetics and metabolic effects of growth hormone injected subcutaneously in growth hormone deficient patients: thigh versus abdomen.

OBJECTIVE: The absorption of insulin following subcutaneous (s.c.) injection is faster in the abdomen than the thigh. We therefore studied the effect of changing the site of injection on the absorption and metabolic effects of human growth hormone. DESIGN AND MEASUREMENTS: In a cross-over study human GH (Norditropin) was injected s.c. in the thigh or abdomen in random order. Ultrasonography of the thigh and abdomen was performed in order to evaluate the thickness of the s.c. tissue. After each treatment period (4 weeks), serum profiles of GH, IGF-I, IGF binding proteins 1 and 3 (IGFBP-1 and IGFBP-3), glucose, insulin, non-esterified fatty acids (NEFA), glycerol, 3-hydroxybutyrate, alanine, lactate and glucagon were measured for 37 hours after GH injection (3 IU/m2 at 1900 hour). PATIENTS: Nine GH deficient patients (five males, four females). RESULTS: The mean (+/- SEM) thickness of the s.c. tissue (mm) was higher on the abdominal site (9.35 +/- 1.38 (thigh), and 22.61 +/- 2.19 (abdomen), P < 0.001). Mean (+/- SEM) integrated levels (area under the curves (AUC) divided by time) of GH (mU/l) were identical: 5.54 +/- 0.70 (thigh) versus 5.48 +/- 0.64 (abdomen) (P = 0.91). AUC (mU/l) for the initial 6 hours were, however, significantly different (14.10 +/- 3.76 (thigh) and 19.02 +/- 3.18 (abdomen), P = 0.02). Maximal serum concentration (Cmax) (mU/l) 23.18 +/- 3.86 (thigh) and 29.66 +/- 4.78 (abdomen) (P = 0.19) was achieved faster (Tmax) following injection in the abdomen. Tmax (hours) was 5.89 +/- 0.41 (thigh) and 4.26 +/- 0.49 (abdomen) (P < 0.002). Mean IGF-I levels (microgram/l) were unaffected by GH injection sites (355 +/- 60 (thigh) and 365 +/- 63 (abdomen), P = 0.61). Mean IGFBP-3 levels (microgram/l) were significantly different (2100 +/- 143 (thigh), and 2350 +/- 176 (abdomen), P = 0.05). Mean levels of IGFBP-1, insulin, glucose, lipid intermediates, metabolites and glucagon were not significantly different. CONCLUSIONS: Human GH was absorbed faster when injected s.c. in the abdomen as compared with the thigh, despite the thicker s.c. tissue on the abdomen. Apart from higher IGFBP-3 levels after s.c. injections in the abdomen, similar metabolic effects of GH were obtained with the two injection sites.

Abdomen↗

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