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Background: To prevent anaphylaxis-associated illness, intramuscular epinephrine injection is recommended. Subcutaneous injection may reduce efficacy, and intraosseous injection promotes morbidity. A few studies suggested that commercially available thigh epinephrine autoinjectors (EAIs) may induce subcutaneous/intraosseous injection in some adults., Objective: To estimate the subcutaneous/intraosseous-injection rates of 4 EAIs by comparing their needle lengths with the ultrasound-measured skin-to-muscle depth and skin-to-bone depth of the midthigh of adults with allergic diseases in a cross-sectional study and to determine patient factors that predict subcutaneous EAI injection., Methods: Thigh ultrasound was conducted in a convenience-recruited cohort with minimal and maximal compression to estimate the effect of EAI-induced compression. Subcutaneous/intraosseous-injection rates were estimated for Anapen (BioProject), EpiPen (Mylan), Jext (ALK), and Emerade (Medeca). Multivariate analyses for subcutaneous-injection risk were conducted with age, male/female sex, abdominal and thigh circumferences, and upper-arm skinfold thickness., Results: A total of 68 patients were recruited. Compression thinned the subcutaneous tissue and muscle by 1 and 9 mm, respectively, on average. Projected subcutaneous-injection rates with/without compression were high for Anapen (65%-66%), moderate for EpiPen and Jext (29%-38%), and lowest for Emerade (13%-21%). Compression introduced a small intraosseous-injection risk with Emerade (4%). Female sex predicted subcutaneous injection (odds ratio, 1.3-2.0; all P < .001). Depending on the EAI, 29% to 97% of women and 0% to 41% of men would be injected subcutaneously. Older men were at risk of intraosseous Emerade injection. Obesity-related variables predicted subcutaneous injection poorly., Conclusion: Anapen was associated with high subcutaneous-injection rates. EpiPen and Jext were projected to provide intramuscular injection in all men without risk of intraosseous injection. Emerade yielded the lowest subcutaneous-injection rates in women. Compression largely affected the muscle., Trial Registration: ClinicalTrials.gov Identifier: NCT02886468., Competing Interests: Disclosures The authors have no conflicts of interest to report., (Copyright © 2024 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

School teachers are often inadequately prepared to use an adrenaline auto-injector (AAI), resulting in potentially dangerous treatment delays. The purpose of this study was to assess the observed competence, and self-reported confidence, of primary school teachers in the Republic of Ireland (RoI) to use an AAI. An evaluation of whether there was a link between confidence and competence was also assessed. Teachers from four primary schools in the RoI completed a questionnaire to assess their prior level of experience, training, and confidence levels with AAI administration. The four steps in administrating trainer AAI to a mannequin simulator were then assessed. A total of 61 teachers participated (out of a population of 80). The mean self-reported confidence was 1.82 out of 5 (SD = 0.96). There was no significant difference in confidence between trained and untrained participants (U = 240.5, NS). Participants who had received AAI administration training performed significantly more of the steps correctly (mean = 3.85, SD = 0.95) as compared to those who had received no training (mean = 2.97, SD = 1.10; U = 180.5, p = 0.008). There was no correlation between confidence in administrating AAI and the percentage of steps in the procedure performed correctly (rho =  -0.17, NS).  Conclusion: Improvements in readiness to administer AAIs can be achieved through the application of more effective approaches to teaching clinical skills, changes to school policies and practices, and consideration of the design of AAIs in order to make their operation safer and simpler. It is important that teachers have the confidence and competence to safely administer an AAI. What is Known: • Poor ability in adrenaline auto-injector use seen across population groups-healthcare professionals, patients, carers, and school staff • Training in the use of adrenaline auto-injectors has positive impact on competency What is New: • Irish school teachers show poor levels of competency in adrenaline auto-injector use • No observed correlation between reported confidence and competency., (© 2024. The Author(s).)

Aim: The aim of the study was to assess the impact of a video training program (VTP) on primary school teachers' skills in using an adrenaline auto-injector (AAI), in correlation with knowledge regarding allergies, in cases of anaphylaxis., Methods: A questionnaire on teachers' knowledge of allergies and on their level of confidence in using an AAI was distributed in primary schools in the French department of Manche (2173 teachers). A VTP followed this questionnaire. A second questionnaire was then distributed. Theoretical knowledge was assessed with a score out of 20. The confidence level was rated on a scale from 1 to 4., Results: We collected 218 responses to the first questionnaire (10.0 % of the population included). The response rate to the second questionnaire was 4.7 % (103 participants), and from this group, 93 of the 103 participants viewed the video (90.3 %). Overall, 76 of the 218 (34.9 %) participants who completed the first questionnaire also completed the second questionnaire and watched the VTP. The number of participants who completed the whole survey was 76 (out of 2173, 3.5 %). The VTP significantly improved teachers' knowledge of the subject of allergies (the average score increased by 2.11 points, p < 0.001) as well as their confidence in recognizing the signs of a severe allergic reaction and in using an AAI: 85.4 % (n = 88) of self-confident teachers after the VTP versus 42.3 % (n = 92) before the VTP (p < 0.001)., Conclusion: The VTP improved teachers' level of knowledge and confidence in using an AAI in cases of anaphylaxis. A similar VTP could be circulated more widely in schools to offer easy access to training tools about allergies., Competing Interests: Declaration of competing interest None., (Copyright © 2024 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

It has previously been shown that EpiPen® autoinjectors are likely to activate normally following up to five excursions to -25°C but data about the post-freezing performance of other brands of adrenaline autoinjectors has not previously been published. Additionally, conditions experienced by polar medics may be substantially colder than this and the performance of adrenaline autoinjectors following more extreme freeze-thaw cycles remains uncharacterised. Investigators in Antarctica and the United Kingdom performed laboratory testing on two brands of adrenaline autoinjector, EpiPen® and Jext® (12 devices of each type). A single freeze-thaw cycle involved freezing the device to -80°C then allowing it to come to room temperature. Devices were exposed to 0, 1, 5 or 15 freeze-thaw cycles. The mass of liquid ejected from each device, when activated, was then measured. No significant differences in the mass of the liquid ejected was found between the test groups. Multiple freeze-thaw cycles to -80°C are unlikely to significantly impact the amount of adrenaline solution expelled from EpiPen® and EpiPen® autoinjectors. This preliminary finding encourages further work investigating the safety and effectiveness of adrenaline autoinjectors after exposure to very low temperatures. This information would be valuable for future polar medics planning and delivering medical provision in extreme environments.

Background: Epinephrine autoinjectors (EAs) are the standard of care for severe food allergic reactions, although they are frequently underused or misused., Objective: To understand the factors associated with underuse of EA by caregivers of pediatric patients with food allergy., Methods: A survey was administered to 200 caregivers of pediatric patients with food allergies to assess most severe lifetime allergic reaction, EA education, and use and factors associated with incorrect use or underutilization., Results: A total of 164 surveys were completed; of which 118 (72%) of lifetime most severe reactions warranted EA use, but the EA was used in only 45 (38.1%). Reasons caregivers indicated for not administering the EA included the following: reactions did not seem severe enough; it was the patient's first allergic reaction; use of other medication; and fear of using EA., Conclusion: Multiple factors contribute to underuse of EA in the treatment of severe allergic reactions. Results from this study highlight the need for continuous EA education in caregivers of and pediatric patients with food allergies, using a multipronged approach targeting clear symptom recognition and alleviation of fear of EA use., (Copyright © 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

This study was conducted to evaluate the effect of ShotBlocker on the intramuscular injection pain and satisfaction in emergency adult patients. This research was designed as a randomized controlled, double-blind, experimental study. The study was conducted with 74 patients who applied to the adult emergency department. Patients were randomized to ShotBlocker and control groups. Patient Assessment Form, Visual Analog Scale, and Visual Analog Patient Satisfaction Scale were used. The mean scores of postinjection pain and satisfaction level were analyzed between the groups; it was determined that while postinjection pain mean score of the experimental group was statistically significantly lower than that of the control group (p = 0.0001), satisfaction scores were statistically significantly higher in the experimental group than in the control group (p = 0.004). When the correlation between the intragroup Pain Scores (VAS) and the Satisfaction Scores (VAS) of the groups after injection was examined, a statistically significant and inverse correlation was found (p < 0.05). It was determined that ShotBlocker was effective in reducing intramuscular injection pain and increasing satisfaction levels., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Our objective in this study was to determine the biocompatibility and hemocompatibility of thin film metallic glass (TFMG) and its potential use in hypodermic needles for intramuscular or intravenous injection. Mouse and rabbit models were employed under approval from the Institutional Animal Care and Use Committee (n = 5/group, two groups in total for both animal models). Platelet-rich plasma (PRP) was collected from the whole blood of rabbits (ear vein) without anti-coagulant for use in in vitro coagulation tests. Histological analysis and optical microscopy were used to assess the endothelial structure of the inner lining of veins after being punctured with needles and detained for 3 days. Histological analysis of ear vein sections revealed that the extent of endothelial damage after puncturing with a TFMG-coated needle was 33% less than that produced by bare needles. Our results confirm that the deposition of a thin TFMG layer (e.g., Zr 53 Cu 33 Al 9 Ta 5 ) on the surface of hypodermic needle can have remarkably clinical benefits, including anti-adhesion, reduced invasion, and minimal endothelial damage. Our results also confirm the good biocompatibility and hemocompatibility of the TFMG coatings.

Aims: Accidental injury to digits with Adrenaline Auto-injectors (AAIs) is becoming increasingly common. Digital AAI injury causes painful ischaemia that can lead to necrosis and patient anxiety. There is a lack of understanding amongst surgeons regarding how to manage these injuries. We aimed to determine an optimal treatment algorithm for their management., Methods: We conducted a systematic review using the search engines MEDLINE, PubMed, EMBASE, CINAHL, BNI, AMED, Google Scholar. Search items included ("epinephrine OR adrenaline") AND ("Digit" OR "Finger" OR "Thumb") AND ("Injury" OR "Accidental")., Results: A total of 49 articles were identified describing 111 cases. In 58 cases; 52% of cases were managed with phentolamine, 24% were managed with nitroglycerine and 7% were treated with warm soaks. The remaining 17% of cases were managed with a variety of alternative treatments. Mean recovery time following treatment with phentolamine infiltration was 33 min, whilst symptoms persisted for several hours in some cases with observation/warm soaks and nitroglycerine. Phentolamine was more effective when injected into the AAI puncture site (mean resolution time: 17 min) in comparison to injection as a digital block (74 min)., Conclusion: Phentolamine is the most effective method of reversing symptoms and treating ischaemic digits when compared to alternative therapies. Symptoms resolved much quicker when phentolamine was infiltrated into the site of injury compared to being infiltrated as a digital block. We propose a treatment algorithm for management of these injuries. Hand surgeons should be aware of AAI injuries and be able to advise on their management., Competing Interests: Declaration of Competing interest The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues., Recent Findings: This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices., Summary: Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.

There are several situations such as medical emergencies and incidents involving mass casualties where drugs and antidotes have to be administered immediately along with other first aid at the site of the event. Self-administration by the affected person or by a companion is required as a life-saving measure. Autoinjector devices (AIDs) are useful for the rapid administration of drugs and antidotes and they can also be used by those who have not been medically trained. This makes them very convenient for emergency and mass casualty management. An AID has a drug cartridge with an embedded needle for subcutaneous or intramuscular injection, which is usually painless. The drugs are delivered slowly by the AID across a large area in the muscle, which increases the absorption and the drug effects are equal to that of intravenous administration. A variety of AIDs are available, such as atropine and pralidoxime for nerve agent poisoning, epinephrine for anaphylactic shock and allergy, diazepam for seizures, sumatriptan for migraine, amikacin for antibacterial treatment, buprenorphine for pain relief and monoclonal antibodies for a variety of diseases. This review describes the published peer-reviewed literature identified by online searches of journal databases.

Background: Use of same length needle for intramuscularly administered vaccines had been reported to cause under-and over-penetration among infants due to their different body weights and underlying variations in the fat and muscle thickness. Normative data regarding thigh compartment thickness are, however, lacking among neonates and infants aged ≤12 weeks particularly in low- and middle-incoming countries with high burden of low birth weight/growth restricted infants., Methods: Present study investigated skin to muscle and skin to bone (STBD) distances of anterolateral thigh of babies (n = 300) aged ≤12 weeks (1-80 days) with different weight groups (<3 kg, 3-4 kg and >4 kg) by ultrasonography during their intramuscular vaccinations., Results: Overall, mean [standard deviation (SD)] STBD was 17.04 (2.66) mm with range of 10.60-23.30 mm. Stratifying by current body weight, mean (SD) STBD in infants weighing less than 3 kg was 14.39 (1.23) mm. For infants weighing between 3-4 kg and >4 kg, the mean (SD) STBD were 16.69 (1.43) mm and 17.04 (2.66) mm, respectively. Estimated safety (no risk of over-penetration) of 16 mm was observed in 57.33% (172) infants whereas 25 mm needle had 100% over-penetration risk in the study cohort. Current body weight of infants was a significant predictor of safe injection [area under the receiver operating characteristic (ROC) curve 0.95; 95% CI 0.92-0.97]., Conclusions: Our study offers objective normative measurements of anterolateral thigh for safe intramuscular vaccination in young infants especially for low birth weight and growth restricted infants in low- and middle-income countries., (© The Author(s) [2019]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Competing Interests: Nil.

Background: Penicillin G Benzathine (PGB) is the cornerstone of syphilis treatment. However, its intramuscular (IM) administration is associated with pain at the site of injection. The dilution of PGB with local anesthetics is recommended in some guidelines, but the evidence that supports it, particularly in adults and in HIV infection, is scarce. Preliminary clinical experience also suggests that the IM administration of PGB through increased needle gauges might improve its tolerability. The aim of the study to identify less painful ways of administering IM PGB in the treatment of syphilis in adults., Methods: Multicenter, randomized, double-blinded clinical trial in patients diagnosed with primary syphilis that required a single IM injection of PGB 2400,00 IU. Patients were randomized to receive PGB diluted with 0.5 mL mepivacaine 1% (MV) or PGB alone, and both groups either with a long 19G or short 21G IM needle. The primary objective was the effect on local pain immediately after the administration through a visual scale questionnaire on pain (0 to 10)., Results: One hundred eight patients were included, 27 in each group. Ninety-four (94.4%) were male, and 41.7% were also HIV-infected. Mean age 36.6 years (SD 11). Significant differences in immediate pain intensity were observed when comparing the long 19G group with anesthesia (mean pain intensity, [MPI] 2.92 [CI 95% 1.08-4.07]) vs long 19G without anesthesia (MPI 5.56 [CI 95% 4.39-6.73), p < 0.001; and also between short 21G group with anesthesia (MPI 3.36 [CI 95% 2.22-4.50]) vs short 21G without anesthesia (MPI 5.06 [CI 95% 3.93-6.19]), p = 0.015). No significant differences in immediate pain were observed between 19G and 21G in the presence or absence of anesthesia (p = 1.0 in both cases). No differences were found between study arms after 6 and 24 h., Conclusions: The IM administration of 1% mepivacaine-diluted PGB induces significantly less immediate local pain as compared to PGB alone. The needle gauge did not have any effect on the pain. Based on these results, we suggest anesthetic-diluted IM PGB as the standard treatment for primary syphilis., Trial Registration: EudraCT 2014-003969-24 (Date of registration 18/09/2014).

Objectives: To compare the efficacy of ShotBlocker and cold spray in reducing intramuscular (IM) injection-related pain in adults. Methos: A prospective, randomized, controlled study carried out between January 2018 and March 2018 at the Department of Emergency Medicine, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey. Adult patients receiving IM injection of diclofenac sodium (75 mg/3 ml) were included. The patients were randomized into 3 groups: ShotBlocker, cold spray, and control. Each group comprised 40 patients. Patients were instructed to rate the intensity of IM injection-related pain using a 100-mm visual analog scale (VAS). Visual analog scale scores of the patients were statistically analyzed. Results: Visual analog scale scores were lower in the ShotBlocker (11 mm) and cold spray (10 mm) groups than in the control group (31 mm) (p=0.001). There were no significant differences in VAS scores between the ShotBlocker and cold spray groups. The operators' responses revealed that ShotBlocker was more difficult to administer than cold spray. Conclusion: ShotBlocker is an effective non-pharmacological method that reduces IM injection-related pain and is similar in efficacy, to cold spray.

Background: Awareness about food allergy and food-induced anaphylaxis (FIA) has increased dramatically over the past decade. It remains unclear, however, whether concordance with guidelines for FIA management has improved over time., Objective: Our objective was to describe changes in emergency department (ED) concordance with guidelines for FIA management., Methods: We analyzed data from 2 multicenter retrospective studies of patients with food-related acute allergic reactions seen in 1 of 17 EDs during 2 time periods: 1999 to 2001 and 2013 to 2015. Visits were identified similarly across years-for example, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.60, 995.61-995.69, 995.0, and 995.3. Anaphylaxis was defined as an acute allergic reaction with involvement of 2+ organ systems or hypotension. We compared concordance between time periods for 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for an epinephrine autoinjector (EAI), (3) referral to an allergist/immunologist, and (4) instructions to avoid offending allergen., Results: We compared 290 patients with FIA during 1999 to 2001 and 459 during 2013 to 2015. Any treatment with epinephrine (pre-ED or in the ED) for patients with FIA increased over time (38% vs 56%; P < .001). Prescriptions for EAI at discharge (24% vs 54%; P < .001) and documentation for referral to an allergist/immunologist (14% vs 24%; P = .001) approximately doubled, whereas instructions to avoid the offending allergen did not change significantly (37% vs 43%; P = .08). Receipt of 3+ guideline recommendations remained low but almost quadrupled over the study interval (6% vs 23%; P < .001)., Conclusions: Over the nearly 15-year study interval, we observed clinically and statistically significant increases in ED concordance with epinephrine-related guidelines for FIA. Management gaps remain and interventions to standardize care still appear warranted., (Copyright © 2019. Published by Elsevier Inc.)

Background: In-flight food-allergic reactions are rare events, but given increasing reports, grass-root advocates have lobbied to replace aircraft emergency kit epinephrine ampules with autoinjectors., Objective: To evaluate the cost-effectiveness of stock epinephrine on commercial aircraft., Methods: We conducted a Markov model with microsimulation of food-allergic individuals over an 80-year time horizon to evaluate the cost-effectiveness of supplementing airline medical kits with epinephrine autoinjectors (eg, providing autoinjector twin-packs in addition to the epinephrine ampule in the medical kit), versus not doing so, using a per-plane annual value-based cost ceiling of $338 (the value-based ceiling for school stock epinephrine). We assumed that autoinjector availability reduced fatality risk by 10%., Results: Equipping all commercial aircraft with autoinjectors cost $2,470,422/year ($0.08/passenger-at-risk), from a societal perspective and when distributed over all at-risk travelers. Over the model horizon, the supplemental autoinjector strategy cost $32,329.29 (standard deviation [SD], $4024.32) versus $32,326.70 (SD $4024.29), produced 26.8917 quality-adjusted life-years (QALYs) (SD, 2.9720) versus 26.8915 (SD, 2.9725), with a lower fatality rate (0.00012; SD, 0.01095 vs 0.00015; SD, 0.1225) versus the ampule-only strategy. The incremental cost-effectiveness ratio of supplemental airline epinephrine autoinjectors was $10,766/QALY in the base-case analysis. The supplemental model remained cost-effective at a willingness to pay threshold of $100,000/QALY if it produced a minimum 1.4% annual food allergy fatality risk reduction, and dominated if it lowered diversion risk or event-related medical care costs-per-event by 10%, respectively., Conclusions: Under base-case scenarios, an airline supplemental stock epinephrine model is cost-effective, with a high value-based cost-ceiling and low annual cost per passenger-at-risk of $0.08., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Limited real-world data exist regarding patient carrying compliance and confidence in using different types of epinephrine autoinjectors (EAIs)., Objective: To perform a Real-world Assessment of Patients' Carrying Time and Confidence with Epinephrine Autoinjector Devices (RACE survey)., Methods: This was a noninterventional survey of patients (≥7 years) who filled 1 or more prescription for Auvi-Q or EpiPen between January 2013 and January 2014. Outcomes included proportion of patients carrying their EAI all the time in the last 7 days (primary), EAI use confidence (secondary), and EAI training experience (secondary). Multivariate regression analyses controlled for significant differences in demographic and clinical characteristics between EAI groups., Results: The survey included 2,000 participants (Auvi-Q, N = 1,000 [children, n = 597; adults, n = 403]; EpiPen, N = 1,000 [children, n = 105; adults, n = 895]). After adjusting for confounding factors, we found that Auvi-Q respondents were more likely to carry their device all the time in the last 7 days versus EpiPen respondents (adjusted odds ratio [aOR], 1.91; 95% CI, 1.49-2.45; P < .001); similar trends were observed in adults and children (P < .001 both). Adults in the Auvi-Q group were more likely to feel "very confident" about correctly using their EAI (aOR, 2.02) and someone else correctly using their EAI (aOR, 2.25) versus the EpiPen group (P < .001 both). Compared with EpiPen respondents, Auvi-Q respondents were more likely to feel that EAI instructions were "very clear" (aOR, 3.10) and more likely to find the prescription pack trainer helpful (aOR, 2.29; P < .01 both)., Conclusions: This study suggests significant real-world differences in patients' carrying time, confidence in use, and training experiences between Auvi-Q and EpiPen users., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The variation of needle lengths of epinephrine auto-injectors (EAIs) has not been investigated., Objective: To investigate the impact of the variation of the needle length of EAIs., Methods: Skin-to-muscle (STMD) and skin-to-bone distances (STBD) were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, applying high or low pressure on the probe. The risk of subcutaneous and periosteal/intraosseous injection was calculated using the lower and upper acceptance limits for length of EAI needles as provided for 3 high-pressure EAIs (HPEAI) and 1 low-pressure EAI (LPEAI)., Results: The variation in needle length of the HPEAIs are for Epipen Jr/Epipen 5 mm, for Jext 2 mm, for Auvi-Q 2.5 mm, and for the LPEAI, Emerade, 1.5 mm. When using the longest acceptable needles for Epipen Jr, the risk of intraosseous/periosteal penetration was highest in children weighing less than 15 kg at 60% and for Jext at 43%. The risk was low for Auvi-Q and Emerade. The risk of subcutaneous injection was greatest with the shortest needles of the Auvi-Q 0.1 mg at 94% in children weighing less than 15 kg. In adults, the risk of subcutaneous injection using the shortest needles was for Epi-Pen at 41%, Jext at 36%, Auvi-Q at 38%, and Emerade at 12%., Conclusion: The variation in needle length of EAIs influences the risk of subcutaneous and intraosseous/periosteal injections. Compared with Epipen Jr, the Auvi-Q 0.1 mg for children weighing less than 15 kg had a low risk of intraosseous/periosteal injection but a very high risk of subcutaneous injection. For adults, there is a significant risk of subcutaneous injection., (Copyright © 2019. Published by Elsevier Inc.)

Background: Intradermal administration of fractional inactivated poliovirus vaccine (fIPV) is a dose-sparing alternative to the intramuscular full dose. We aimed to compare the immunogenicity of two fIPV doses versus one IPV dose for routine immunisation, and also assessed the immunogenicity of an fIPV booster dose for an outbreak response., Methods: We did an open-label, randomised, controlled, inequality, non-inferiority trial in two clinics in Dhaka, Bangladesh. Healthy infants were randomly assigned at 6 weeks to one of four groups: group A received IPV at age 14 weeks and IPV booster at age 22 weeks; group B received IPV at age 14 weeks and fIPV booster at age 22 weeks; group C received IPV at age 6 weeks and fIPV booster at age 22 weeks; and group D received fIPV at 6 weeks and 14 weeks and fIPV booster at age 22 weeks. IPV was administered by needle-syringe as an intramuscular full dose (0·5 mL), and fIPV was administered intradermally (0·1 mL of the IPV formulation was administered using the 0·1 mL HelmJect auto-disable syringe with a Helms intradermal adapter). Both IPV and fIPV were administered on the outer, upper right thigh of infants. The primary outcome was vaccine response to poliovirus types 1, 2, and 3 at age 22 weeks (routine immunisation) and age 26 weeks (outbreak response). Vaccine response was defined as seroconversion from seronegative (<1:8) at baseline to seropositive (≥1:8) or four-fold increase in reciprocal antibody titres adjusted for maternal antibody decay and was assessed in the modified intention-to-treat population (infants who received polio vaccines per group assignment and polio antibody titre results to serotypes 1, 2, and 3 at 6, 22, 23, and 26 weeks of age). The non-inferiority margin was 12·5%. This trial is registered with ClinicalTrials.gov, number NCT02847026., Findings: Between Sept 1, 2016 and May 2, 2017, 1076 participants were randomly assigned and included in the modified intention-to-treat analysis: 271 in Group A, 267 in group B, 268 in group C, and 270 in group D. Vaccine response at 22 weeks to two doses of fIPV (group D) was significantly higher (p<0·0001) than to one dose of IPV (groups A and B) for all three poliovirus serotypes: the type 1 response comprised 212 (79% [95% CI 73-83]) versus 305 (57% [53-61]) participants, the type 2 response comprised 173 (64% [58-70]) versus 249 (46% [42-51]) participants, and the type 3 response comprised 196 (73% [67-78]) versus 196 (36% [33-41]) participants. At 26 weeks, the fIPV booster was non-inferior to IPV (group B vs group A) for serotype 1 (-1·12% [90% CI -2·18 to -0·06]), serotype 2 (0·40%, [-2·22 to 1·42]), and serotype 3 (1·51% [-3·23 to -0·21]). Of 129 adverse events, 21 were classified as serious including one death; none were attributed to IPV or fIPV., Interpretation: fIPV appears to be an effective dose-sparing strategy for routine immunisation and outbreak responses., Funding: US Centers for Disease Control and Prevention., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Infant anaphylaxis is an emerging risk, with food allergy the most common cause. Although the presentation of anaphylaxis involves the same systems as in older children and adults, there are real-world challenges to identifying symptoms of an allergic emergency in nonverbal children, as well as implementing optimal treatment. Recognition of anaphylaxis in infants can be challenging because allergic symptoms and certain normal infant behaviors may overlap. Intramuscular epinephrine is the treatment of choice for infants, as it is for older children and adults, and an epinephrine autoinjector approved by the Food and Drug Administration is now available for infants weighing between 7.5 and 15 kg. A panel of experts sought to develop guiding principles for the recognition, diagnosis, and management of anaphylaxis in infants, and provide a framework for the development of new guidelines and future research. Accordingly, anaphylaxis emergency action planning for infants was addressed by the panel. In considering formation of future infant anaphylaxis guidelines, health care providers should be aware of the needs to improve the recognition, diagnosis, and management of infants with anaphylaxis. Future research should identify and validate clinical criteria for the diagnosis of anaphylaxis in infants, as well as risk factors for the most severe reactions., (Copyright © 2019. Published by Elsevier Inc.)

Background: Fat grafting for gluteal augmentation is one of the most popular aesthetic surgery procedures. It has an associated mortality to fat embolism of 0.2%., Objectives: The authors of this study sought to describe which technique for synthetic graft application was least likely to cause a fat embolism., Methods: Ten fresh bodies were obtained and 4 groups arranged with 5 buttocks each randomly assigned. Group 1 was infiltrated through the upper medial intergluteal sulcus (upper medial intergluteal sulcus) with an angulation of -30°, -10°, and 0°. Group 2 was infiltrated through the middle lower gluteal sulcus with an angulation of -30°, 0°, and +15°. Group 3 was infiltrated through a peritrochanteric (PT) access at the level of the femur head at 0° and +10° and in the middle of the buttock at the level of the posterior superior iliac crest at -30° toward the trochanter (lateral direction). Group 4 was infiltrated in the same manner as group 1 without -30°. A complication occurred when the graft was in contact with the vascular or nervous bundle, within the gluteus medius muscle, or both., Results: Group 1 had 3 buttocks with a complication (UMIGS -30°). Group 2 had complications in all the injection techniques. Group 3 had 5 buttocks with a complication (PT at 0°). Group 4 had no complications., Conclusions: The injection of the fat graft through the UMIGS at 0° and 10° angles, and through the middle of the buttock at the level of posterior superior iliac crest a -30° angle, reaches the surface needed for gluteal augmentation. The group 2 techniques should be avoided because they have a high risk of complication.

Background: With rising prevalence of obesity, increasing number of gluteal injections would be expected to fail in intramuscular (IM) drug delivery., Study Question: This study evaluated ventral gluteal fat thickness (VGT) on adult magnetic resonance imaging of pelvis and correlated it with the subjects' body mass index (BMI), weight, and height to establish evidence-based clinical estimates of individualized needle length and suitability of ventral gluteal site for IM injections., Design: Retrospective review., Study Design, Measures and Outcomes: Three hundred fifty adult (224 women, 126 men) magnetic resonance imaging scans of pelvis were reviewed to measure the VGT as the distance between the skin and the nearest edge of the gluteus medius muscle at the recommended ventral gluteal injection site. VGT was correlated with BMI, weight, and height by multivariate analysis., Results: Fifty-three (49 women, 4 men) subjects had VGT greater than 3.3 cm, and 146 (106 women, 40 men) subjects had VGT greater than 2.0 cm. The Pearson correlation coefficient between VGT and BMI was 0.82 for women and 0.81 for men. The difference between the VGT in men and women of comparable BMI was statistically significant (P < 0.001). BMI of 30 in women and 35 in men seem to be upper limits for successful ventral gluteal IM injections with 3.75-cm (1.5-inch) hypodermic needle. The expected failure rate of ventral gluteal IM delivery with the 3.75-cm needle is 71% in women with BMI >30, and 60% in men with BMI >35., Conclusion: BMI is reliably predictive of VGT in both men and women for selecting appropriate needle length for IM injections at this site. Standard needles would fail in IM delivery at this site in a considerable proportion of obese adults. Because of high prevalence of obesity in individuals with severe mental illness, our findings could significantly impact acute and maintenance therapy with injectable tranquillizers and antipsychotics.

Aim: The aim of this study was to investigate the effect of the Buzzy application on pain and satisfaction during injections., Background: Intramuscular injections usually cause some degree of pain at the injection site. Patients are often afraid of receiving injections because they perceive that it will be painful., Design: The study was a single-blind, randomized controlled trial., Method: Patients (n = 65) who receive diclofenac sodium intramuscularly at a state hospital in a city in the western region of Turkey were included in the study. The study data were collected by The Patient Information Form and Visual Analog Scale (VAS). Pain intensity and injection satisfaction scores were evaluated using the VAS., Results: According to the findings of this research, the post-injection pain intensity and injection satisfaction scores of patients in the application group were found to be higher than in the control group., Conclusion: In conclusion, the Buzzy device has the potential to reduce injection related pain in adult patients who may be fearful of receiving such injections., (Copyright © 2018 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Background: The unintentional usage of adrenaline auto-injectors may cause injury to caregivers or patients. To prevent such incidents, we assessed the causative factors of these incidents., Methods: The Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which adrenaline auto-injectors were unintentionally used. One hundred cases were reported from June 2015 to March 2016. We identified the root causes of 70 child and 25 adult cases, separately., Results: The incidents occurred with repeated prescriptions as well as the first prescription. Three cases resulted in a failure to administer an adrenaline auto-injector to children with anaphylaxis. Four caregivers used it with improper application (epilepsy or enteritis). Among the child cases, the median age at the time of the incident was 5.5 years (range, 2-14 years). Five children injected the adrenaline auto-injector on their own body trunk. Twenty children were not the allergic patients themselves. Improper management protocol of the device and the child's development were concomitantly involved in most of the cases. A variety of human behaviors were identified as the root causes in the adult cases. At least 34 cases were associated with mix-ups between the actual and training device., Conclusions: Health workers should provide sufficient education regarding safety use of adrenaline auto-injector for caregivers tailored to their experience levels at both first and repeated prescriptions. Such education must cover anticipatory behavior based on normal child development. Devices should also be further improved to prevent such incidents., (Copyright © 2018 Japanese Society of Allergology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: This is an update of a Cochrane Review first published in 2015. The conclusions have not changed.Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents., Objectives: To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration)., Search Methods: We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers., Selection Criteria: Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years., Data Collection and Analysis: Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system., Main Results: We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-Hep B) antigen components.Primary outcomesIncidence of vaccine-preventable diseases: No trials reported this outcome.Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low-quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate-quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant.Secondary outcomesImmune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (moderate-quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured).Severe and non-severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non-severe local reactions after DTwP-Hib vaccination compared with 25 G 16 mm needles (moderate-quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non-severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses.Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low-quality evidence, two trials, 100 to 459 participants in analyses).Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence., Authors' Conclusions: Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in low- and middle-income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

Background: Intramuscular epinephrine is the first line drug in the treatment of anaphylaxis. This study was to identify the appropriateness of 1 inch needle length for epinephrine prefilled syringes in children., Methods: Children aged 1 month to 18 years were enrolled. Skin to muscle depth (STMD) and skin to bone depth (STBD) were measured using an ultrasonography at the mid-anterolateral thigh. A 1 inch needle was considered as being appropriate if the STBD was more than 1 inch and the STMD was less than 1 inch., Results: Seventy five infants, 75 pre-school aged children, 75 school aged children and 147 adolescent were enrolled: 196 (52.7%) children were male. A 1 inch needle length was appropriate for 61% of the infants, for 88% of the preschool children, for 99% of the school aged children and for 95% of the adolescents. Thigh circumference ≥23 cm, BMI ≥16 kg/m2 and BW ≥ 6 kg in infants provided the sensitivity of 74%-96% in predicting the appropriateness of 1 inch needle. In preschool group, thigh circumference ≥25 cm, BMI ≥13.5 kg/m2 and BW ≥ 10 kg provided the sensitivity of 98.5-100% in predicting the appropriateness of 1 inch needle. Thigh circumference ≥ 49 cm in adolescents provided the sensitivity of 75% in predicting that a 1 inch needle was too short., Conclusion: One inch needle length may not be appropriated for intramuscular injection at thigh in all children. Thigh circumference, BMI and body weight are useful for predictor for using the 1 inch needle.

Background: ZENEO® (Crossject, Dijon France) is a novel prefilled, disposable needle-free auto-injector (AI) device under development for drug deliverer in a variety of routine-use or emergency situations. At present, reported user experience and patient preferences are limited. To determine what impact different forms of user instructions may have on successful use of the ZENEO® device., Methods: We conducted a human factors study on 134 healthy volunteers. On enrolment, subjects were provided with different instructive training material; a device quick guide plus either use of a dummy training device, an illustrated leaflet, or a demonstration video. After 6 weeks, subjects returned and performed an unaided simulated injection, and compliance with specific steps necessary for successful use, and avoidance of actions that interfere with appropriate use was recorded by an investigator., Results: Most subjects (93.3%) successfully performed a simulated injection without major errors (regardless of type of educational instructions), and the great majority (97.5%) reported no difficulty in a range of objective measures of important necessary steps. Compliance with necessary steps and avoidance of detrimental actions was greater in those subjects with prior access to a demonstration video or provided with an illustrated patient leaflet. Prior experience with a dummy training device provided little if any benefit. User satisfaction with the device was high., Conclusions: The results show that the ZENEO® device can be effectively used with a conventional suite of printed user instructions. Use of a demonstration video provides additional value, whereas use of a dummy training device had limited value.

Background: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation., Methods: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision., Results: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision ( P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand., Conclusions: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: The appropriate usage of an adrenaline auto-injector (AAI, Epipen ® ) is a key aspect of patient and social education in the management of anaphylaxis. However, although AAIs are being prescribed increasingly frequently, there are few reports on their actual use., Methods: The Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which AAIs were used. Two hundred and sixty-six cases were collected from March 2014 to March 2016., Results: The cases included 240 events of immediate-type food allergies caused by cow's milk (n = 100), hen's egg (n = 42), wheat (n = 40), and peanuts (n = 11). Exercise-related events were reported in 19 cases; however, the diagnosis of food-dependent exercise-induced anaphylaxis with a specific causative food was only made in 4 cases (wheat, n = 2; fish, n = 1; squid, n = 1). The frequent reasons for the causative intake included programmed intake (n = 48), failure to check the food labeling (n = 43), and consuming an inappropriate food (n = 26). AAIs were used at schools or nurseries in 67 cases, with school or nursery staff members administering the AAI in 39 cases (58%). On arriving at the hospital, the symptom grade was improved in 71% of the cases, while grade 4 symptoms remained in 20% of the cases. No lethal cases or sequelae were reported., Conclusions: AAIs were used effectively, even by school teachers. The need to visit a hospital after the use of an AAI should be emphasized because additional treatment might be required., (Copyright © 2017 Japanese Society of Allergology. Production and hosting by Elsevier B.V. All rights reserved.)

Aims: To evaluate the effectiveness and safety of botulinum toxin administration into the inferior head of the lateral pterygoid muscle of patients with jaw opening dystonia by using a computer-aided design/computer-assisted manufacture (CAD/CAM)-derived needle guide., Methods: A total of 17 patients with jaw opening dystonia were enrolled. After the patient's computed tomography (CT) scan was imported and fused with a scan of a plaster cast model of the maxilla, the optimal needle insertion site over the lateral pterygoid muscle was determined using the NobelClinician software. A total of 13 patients were injected both with and without the guide, and 4 patients underwent guided injection alone. The therapeutic effects of botulinum toxin injection and its associated complications were statistically compared between the guided and unguided procedures using paired t test., Results: Botulinum toxin therapy was performed 42 and 32 times with and without the guides, respectively. The needle was easily inserted without any complications in all procedures. There was a significant difference (P < .001) between the mean comprehensive improvements observed with (66.3%) and without (54.4%) the guides., Conclusion: The findings suggest that the use of needle guides during the injection of botulinum toxin into the inferior head of the lateral pterygoid muscle is very useful for aiding the accurate and safe administration of botulinum toxin therapy for jaw opening dystonia.

In this study, we prepared 4 assistive devices (A-D) for Miriopen ® to improve the "ease of holding" and "ease of pushing" and compared their usability with that of a device provided by the pharmaceutical company (S). Fifty-five healthy volunteers in their 20s performed the self-injection maneuver using all 5 assistive devices and ranked them regarding 3 items, i.e., the "ease of holding", "ease of pushing", and "overall ease of administration". In all evaluation items, C was ranked first by the largest number of subjects, and the ranking by the subjects was shown by Kendall's coefficient of concordance to be consistent. In addition, comparison of the distance scale calculated from the ordinal scale showed significantly higher ranks of C and D compared with A, B, and S in all evaluation items. No significant difference was noted between C and D. Since C and D had shapes with concavities and convexities that fit the index, middle, and ring fingers (2nd-4th fingers), the fingers are considered to be better stabilized during the injection maneuver with consequent high ratings. Moreover, the 4 assistive devices prepared in this study were rated to be equal to or higher than S.

Background: Food allergy and anaphylaxis appear to be increasing in the United States, especially in young children, and preparedness is paramount to successful emergency management in the community. Although the treatment of choice for anaphylaxis is epinephrine delivered by autoinjection, some devices are challenged by less user-friendly designs or pose the risk of injury, especially in young patients. Human factors engineering has played a larger role in the development of more recent epinephrine autoinjector technologies and will continue to play a role in the evolution and future design of epinephrine autoinjectors., Objective: To discuss contemporary issues related to the identification and management of anaphylaxis, current and future epinephrine autoinjector design, and unmet needs for the treatment of special populations, namely, young children weighing less than 15 kg., Methods: The literature was reviewed and select articles retrieved to support expert clinical opinions on the need for improved recognition of anaphylaxis, epinephrine autoinjector design, and unmet needs in special populations., Results: Anaphylaxis may be underrecognized and poorly defined in infant- and toddler-aged children, current devices may not be adequate to safely treat these patients (ie, inappropriate needle length), and health care professionals may not be aware of these issues., Conclusion: As epinephrine autoinjector technology continues to evolve, device characteristics that promote safe, user-friendly experiences and give clinicians and their patients confidence to successfully treat anaphylaxis during an emergency, without injury, will be favored., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Epinephrine is the first-line treatment for anaphylaxis. Despite this, there have been identified gaps in the management of anaphylaxis including infrequent or delayed use of epinephrine for acute allergic reactions, as well as inadequate epinephrine autoinjector (EAI) training, and prescription rates of these devices for patients at risk. This paper reviews new data, and new problems in recently published literature on EAIs. A database search was conducted for publications between January 2015 and February 2017 using keywords related to EAIs including their functionality and features, carriage, prescription rates, barriers, and side effects. Eligibility criteria included patients at risk for anaphylaxis, caregivers, and health care professionals. Experimental studies and observational studies were included. Of 1,737 potentially relevant articles, 19 were used for analysis. These articles addressed specific aspects of an EAI, including (1) information on features and functionality; (2) prescriptions; (3) training on their use; and (4) carriage and use at the time of reaction by patients, schools, camps, emergency departments, and paramedics. Our review highlights that existing gaps in anaphylaxis management remain unaddressed. Patient needs are largely unmet, and very few studies are being designed to clarify and instill best practice, and to determine how to increase adherence to existing anaphylaxis guidelines through integrated knowledge translation strategies., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: Given the rarity of contrast reactions in practice, most radiologists have little to no experience in their management, and errors are common. The purpose of this study was to compare treatment of a moderate-severity reaction with intramuscular epinephrine by either the traditional manual method of drawing up and delivering epinephrine with a needle and syringe or the use of an epinephrine autoinjector., Subjects and Methods: All diagnostic radiologists at the study institution were requested to participate in an annual contrast reaction simulation program, which consisted of three simulation scenarios in a high-fidelity simulation laboratory. During the moderate-severity simulation scenario, the time to administer intramuscular epinephrine and any errors in administration were recorded. Groups were randomized to use an autoinjector device or manual delivery. All participants completed a survey assessing the experience with epinephrine and their comfort in treating contrast reactions using a traditional manual approach versus an epinephrine autoinjector., Results: Among 189 participants in the contrast reaction simulation program, 76 participated in a moderate-severity reaction simulation two to five at a time in 25 sessions. Mean total time to administration was significantly longer for manual (108.8 seconds) than for autoinjector (38.7 seconds) delivery (p < 0.001). There were 11 errors in the manual group and one error in the autoinjector group (p = 0.005). Ninety-four percent of participants reported feeling very comfortable or comfortable with the autoinjector as opposed to 60% for manual delivery (p < 0.001). Overall, 96% of participants thought the autoinjector was easier to use., Conclusion: Use of an epinephrine autoinjector for treatment of contrast reactions was associated with a significantly greater degree of provider comfort, shorter time to administration, and fewer errors.

Background: Epinephrine injection represents the standard of care for anaphylaxis treatment. It is most effective if delivered intramuscularly, whereas inadvertent intraosseous injection may be harmful. The needle length in current pediatric epinephrine autoinjectors (EAIs) is 12.7 mm; however, the ideal needle length for infants and toddlers weighing less than 15 kg is unknown., Objective: To determine the skin-to-bone distance (STBD) and skin-to-muscle distance (STMD) at baseline and after simulated EAI application in infants and toddlers (weighing 7.5-15 kg)., Methods: Study participants recruited from 2 North American allergy clinics underwent baseline and compression (10-lb pressure) ultrasonography of the anterolateral thigh with a modified ultrasound transducer mimicking the footprint and maximum pressure application of an EAI device. Ultrasound images, with clinical data masked, were analyzed offline for STBD and STMD in short-axis approach., Results: Of 53 infants (mean age, 18.9 months; 54.7% male; 81.1% white; mean weight, 11.0 kg), 51 had adequate images for short-axis STBD measurements. In these infants, the mean (SD) baseline STBD was 22.4 (3.8 mm), and the mean (SD) STMD was 7.9 (1.7) mm. With 10-lb compression, the mean (SD) STBD was 13.3 (2.1) mm, and the mean (SD) STMD was 6.3 (1.2) mm. An EAI with a needle length of 12.7 mm applying 10-lb pressure could strike the bone in 43.1% of infants and toddlers in this cohort., Conclusion: Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Botulinum toxin (BoNT) has been approved for aesthetic use since 2002. Since then, clinical studies and expert use have informed our understanding of how BoNT exerts its clinical effect and the practical use of this product across a number of aesthetic applications. This review discusses the clinical properties and characteristics of abobotulinumtoxinA, which patients are suitable for its use, and how it can be utilized to treat facial rhytides., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc.)

Nonpharmacologic strategies exist to manage procedural pain in healthy newborn infants. The aim of this prospective randomized controlled trial (RCT) was to examine the efficacy of ShotBlocker for managing injection pain associated with the first intramuscular hepatitis B vaccine given to healthy full-term neonates. This randomized controlled trial study was conducted in a private university hospital in Istanbul, Turkey, in which 100 healthy term neonates were randomly assigned to either a ShotBlocker (n = 50) or control group (n = 50). The Neonatal Infant Pain Scale scores of the neonates in the ShotBlocker and control groups were compared before, during, and after the injections, and the physiological parameters were compared before and after the procedure. The pain scores of the neonates during (ShotBlocker group: 1.64 ± 0.80; control group: 2.96 ± 0.73) and after (ShotBlocker group: 0.74 ± 0.66; control group: 1.42 ± 0.76) the injection procedure were lower in the ShotBlocker group than in the control group (P = .000). The postinjection heart rate in the infants in the ShotBlocker group (145.02 ± 13.50) was found to be lower than in those for whom ShotBlocker was not used (150.24 ± 13.36) (P = .05). The use of ShotBlocker during the hepatitis B vaccine in term neonates is effective in reducing the acute pain.

Introduction: Pediatric obesity threatens the efficacy of medications given intramuscularly. In anaphylactic patients, epinephrine auto-injector needle lengths are potentially too short to reach the muscle compartment in patients with elevated body habitus. The objective of the study was to determine needle-length requirements for intramuscular injections in pediatric patients., Methods: We used ultrasound to measure the distance from skin to muscle compartment of the thigh in 200 pediatric patients of various weight and body mass index who presented to the emergency department., Results: Patients with higher body mass index had an increased distance to muscle and bone. If current recommendations were followed, 5% of patients within the EpiPen adult weight category and 11% of patients within the Centers for Disease Control and Prevention weight category would have potentially used a needle inadequate in length for intramuscular injections., Conclusion: With the increase in childhood obesity, needle lengths may be too short to effectively deliver medications to the intramuscular compartment. Needle length should be evaluated to accommodate pediatric patients with increased skin to muscle distance., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors (EAs). The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Key points emphasized include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular epinephrine injection in the mid-outer thigh reduces hospitalizations, morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine injection in community settings for patients with a history of anaphylaxis and, if specific circumstances warrant, for some high-risk patients who have not previously experienced anaphylaxis; (4) prescribing epinephrine for infants and young children weighing <15 kg, especially those who weigh 7.5 kg and under, currently presents a dilemma, because the lowest dose available in EAs, 0.15 mg, is a high dose for many infants and some young children; (5) effective management of anaphylaxis in the community requires a comprehensive approach involving children, families, preschools, schools, camps, and sports organizations; and (6) prevention of anaphylaxis recurrences involves confirmation of the trigger, discussion of specific allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, if relevant), and a written, personalized anaphylaxis emergency action plan; and (7) the management of anaphylaxis also involves education of children and supervising adults about anaphylaxis recognition and first-aid treatment., (Copyright © 2017 by the American Academy of Pediatrics.)

Cardiac regenerative therapy has received attention as a potentially revolutionary approach for treating the damaged heart. The mouse model of myocardial infarction (MI) remains one of the most common tools for the evaluation of such new therapies. Typically, intramyocardial administration of cells or biomaterials in mice is performed by an open-chest surgical procedure, but less invasive delivery methods are becoming available. Echocardiography-based transthoracic myocardial injection is one such minimally invasive approach that can reliably deliver therapeutics to the target site with limited complications and quick recovery for the animal following the procedure. Here, we will describe the method of echocardiography-guided intramyocardial injection in a mouse MI model.

Background: It is recognized that, as a result of variation in tissue anatomy, current auto-injectors may have insufficient needle length to achieve successful intramuscular agent delivery in a number of patients. The Zeneo ® auto-injector is a novel prefilled, single-use, needle-free device currently in development for intradermal, subcutaneous, and intramuscular agent delivery across a variety of clinical indications. We aimed to evaluate delivery depth of the device calibrated at pressure appropriate for intramuscular (IM) administration., Methods: This was a prospective single-center study in healthy adult volunteers, in whom each received a single injection of saline into the anterolateral thigh. Using sequential MRI scans, we measured skin-to-muscle distance (STMD) agent delivery depth, and the success of IM agent penetration. Device dynamic pressure measurements were also recorded., Results: Results are reported for 37 subjects with evaluable MRI scans; 19 men, 18 women; mean age 38 years (range 20-58); mean BMI 27.0 kg/m 2 (range 21.2-30.8 kg/m 2 ). Mean STMD values were 18.6 mm (range 13.4-23.6 mm) in women and 10.0 mm (range 5.0-21.7 mm) in men, with gender differences due primarily to greater subcutaneous thickness in women. A trend for greater STMD in subjects with BMI greater than 25 kg/m 2 was seen. Mean injectate penetration depths of 30.1 mm (range 20.2-45.6 mm) were observed with values similar in male and female subjects. Successful IM delivery was reported in 95% of subjects. When failure occurred, this was not due to inadequate injection depth. Device pressure (P max ) had the greatest influence on injectate muscle penetration., Conclusion: Use of the Zeneo ® auto-injector achieves delivery depth that ensures intramuscular delivery in both men and women, regardless of BMI. Consistent with other reported data, STMD is greater in women., Funding: Crossject.