A new method to reduce pin-prick pain of intra-muscular and subcutaneous injections

AIM

Although about 10% of the normal population is thought to be needle-phobic, no method to reduce pin-prick pain is currently available for large scale application. We describe a new simple and easy-to-do method to reduce pin-prick pain through the pressure of multiple blunt pins at the injection site.

METHODS

Two-hundred and twelve patients were randomly assigned to 2 groups. The treated group (n= 106) received intramuscular and subcutaneous injections with the application of the blunt pins and the control group (n= 106) with a placebo device. Pain was tested with the visual analogue scale on a 0 (no pain)-10 (maximum pain) scale.

RESULTS

After intramuscular injections a significant (P< 0.0001) pain reduction in the treated group compared to placebo was observed: 1.90+/-1.27 versus 5.16+/-1.37 (mean pain reduction: 63.2%); 88.5% of the patients in the treated group and 11.4% in placebo group rated the pain as = or < 3. After subcutaneous injections mean reported pain in the treated group compared to placebo was: 0.32+/-0.51 versus 2.61+/-0.77 (mean pain reduction: 87.7%) (P< 0.0001); 95.1% of the patients in the treated group and 9.8% in the placebo rated the pain as = or <1. No side effects were observed.

CONCLUSIONS

Multiple blunt pins pressure on the skin, at the time of intramuscular or subcutaneous injection is able to significantly reduce pin-prick pain. The underlying physiological mechanisms are briefly discussed.

[Postoperative pain management using subcutaneous fentanyl and ketamine after abdominal gynecologic surgery]

BACKGROUND

Subcutaneous opioid is one way of managing postoperative pain in patients undergoing anticoagulant therapy. We have evaluated the safety and the efficacy of postoperative pain management using subcutaneous fentanyl and ketamine after abdominal gynecologic surgery.

METHODS

Written informed consent was obtained from 50 ASA physical status 1 or 2 female patients aged between 20 and 65. Patients were randomized to one of 5 groups. Group 1, 2 and 3 received 25, 35 and 50 microg x h(-1) subcutaneous fentanyl infusion, respectively. Group 4 received 25 microg x h(-1) fentanyl and 2 mg x h(-1) ketamine subcutaneously; group 5 received 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine subcutaneously. General anesthesia was administered to all patients. Two hours after induction, subcutaneous infusion of fentanyl and ketamine was started in the patients and discontinued 24 hours after the operation. All patients were assessed twice, at 4 hours and at 24 hours after operation. Blood gas analysis was performed. Number of analgesic administration required during the 24 hours after operation was recorded. Groups 1, 2, 3 and groups 1, 4, 5 were evaluated as one group, respectively. Group differences were analyzed by variance analysis. Differences of analgesic administration were analyzed with Kruskal-Wallis test.

RESULTS

As to anesthetic requirement during the 24 hours after operation, there were no significant differences among treatment groups. With respect to blood gas analysis, only individuals receiving subcutaneous 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine maintained high PaO2 4 hours after the operation (P<0.05).

CONCLUSIONS

We recommend administration of 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine subcutaneously, which maintains high Pao2 and requires less analgesic.

Performing Subcutaneous Injections: A Literature Review

BACKGROUND

Persons using daily subcutaneous injections to administer medicine perform them in different ways and thereby increase the risk of skin complications related to the injection. It is often part of nurses' role to administer medicine and educate the patient in injection technique. Course literature in nursing education, commercial patient education pamphlets, and instructional leaflets do not give consistent advice regarding subcutaneous injection technique.

AIM

The aim of this review was to identify the scientific foundation for the technical performance of subcutaneous injections. The question to be answered was: How should a subcutaneous injection be administered to achieve the right dose in the right place with minimum complications?

METHOD

The review included a search in three databases, a screening process at abstract level, followed by a quality assessment of included articles. The quality assessment was done independently by two people and followed specific protocols.

RESULT

A total of 38 articles were assessed for quality and covered information on dose, location, and complications of subcutaneous injection. The assessed studies are heterogeneous in design and describe different aspects of the subcutaneous injection technique. Therefore, the scientific foundation for technical performance is weak. However, several studies indicate that the amount of subcutaneous fat and appropriate needle length are of high importance for the drug to reach the target tissue.

CONCLUSION

More research regarding effective subcutaneous injection technique needs to be done.

Unilateral subcutaneous bee venom but not formalin injection causes contralateral hypersensitized wind-up and after-discharge of the spinal withdrawal reflex in anesthetized spinal rats

This study aimed to investigate the effect of tonic nociception on spinal withdrawal reflexes including (1) long lasting spontaneous responses elicited by subcutaneous (s.c.) administration of formalin (2.5%, 50 microl) and bee venom (BV, 0.2 mg/50 microl) into the hind paw and (2) corresponding ipsilateral (primary) and contralateral (secondary) hypersensitivity to noxious pinch and repetitive supra-threshold (1.5 x T) electrical stimuli at different frequencies (3 Hz: wind-up; 20 Hz: after-discharge) in anesthetized spinal rats. Spinal withdrawal reflexes were studied by simultaneously assessing single motor units (SMUs) electromyographic (EMG) activities from the bilateral medial gastrocnemius (MG) muscles. Subcutaneous formalin-induced persistent spontaneous SMU EMG responses were in typical biphasic manner with an apparent silent period (about 13-18 min), but in contrast, BV elicited monophasic long lasting (about 1 h) SMU EMG responses without any resting state. The mechanically and electrically evoked responsiveness of SMUs were enhanced significantly by ipsilateral BV injection, whereas enhanced electrically, but not mechanically, evoked responses (including wind-up and after-discharge) were found at the non-injection site of the contralateral hind paw. However, s.c. administration of formalin was only able to establish ipsilateral hypersensitivity of the SMUs to repeated electrical, not mechanical, stimulation. Neither mechanically nor electrically evoked contralateral hypersensitivity of the SMUs was found during the ipsilateral formalin-induced nociception. For pharmacological intervention, intrathecal administration of the non-N-methyl-d-aspartate (non-NMDA) receptor antagonist CNQX (40 nmol/10 microl), but not the non-competitive NMDA receptor antagonist MK-801 (40 nmol/10 microl), significantly depressed BV-induced contralateral hypersensitivity of the SMUs to repeated 3 Hz (wind-up) and 20 Hz (after-discharge) frequencies of electrical stimulation. Using the extracellular SMU recording technique, we found that s.c. administration of formalin and BV shows a significant difference in long lasting spontaneous firing of SMUs. This is consistent with previous observations in animal behavioral studies. Additionally, contralateral electrically evoked hypersensitivity of the SMUs was found only following BV injection, not in the formalin test. The maintenance and development of BV-induced contralateral hypersensitivity of the spinal withdrawal reflex to noxious electrical stimulation indeed depend on different central pharmacological receptors. The spinal non-NMDA, but not the NMDA, receptors may play important role in BV-induced contralateral central hyperexcitability and sensitization.

Subcutaneous interferon-beta injections in patients with multiple sclerosis initiate inflammatory skin reactions by local chemokine induction

Subcutaneous Interferon-beta (IFN-beta) injections for the treatment of multiple sclerosis (MS) frequently cause inflammatory injection site reactions. To study the role of chemokines we obtained skin biopsies from 7 MS patients 24 h after injection. At the IFN-beta but not at the contralateral placebo injection sites, we observed strong IP-10/CXCL10 and moderate MCP-1/CCL2 expression associated with extensive perivascular, highly CXCR3-positive T cell and macrophage infiltrates. Primary human skin cells displayed a comparable pattern of chemokine induction after stimulation with IFN-beta in vitro. IFN-beta may therefore trigger inflammatory skin reactions through local chemokine induction followed by rapid immune cell extravasation.

Force requirements and insulin delivery profiles of four injection devices

BACKGROUND

Injection force requirements for four insulin pen-type injection devices were evaluated using the AGS-IkNG Autograph force measurement device (Shimadzu Corp., Kyoto, Japan).

RESULTS

Compared with the Humulin Pen (the Japanese brand name is Humacart kit; the same device as the Humalog Pen; Eli Lilly, Indianapolis, IN), HumaPen Ergo (Eli Lilly), and NovoPen 3 (Novo Nordisk A/S, Bagsvaerd, Denmark), the InnoLet(Novo Nordisk) required the lowest injection force to both initiate piston movement and commence insulin delivery and required the lowest overall force throughout delivery. InnoLet and NovoPen 3 showed the most even load-displacement curves, suggesting a smoother delivery of insulin during injection. In contrast, the Humulin Pen and HumaPen Ergo demonstrated marked fluctuations in the force required to complete injection.

CONCLUSIONS

These performance characteristics appeared consistent with mechanical features of these insulin delivery devices, and the results highlight the potential importance of careful pen selection for patients with neuromuscular weakness or impaired manual coordination.

Epicutaneously induced TGF-β-dependent tolerance inhibits experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) is a devastating autoimmune disorder of the central nervous system (CNS) with limited treatment modalities. To evaluate the efficacy of epicutaneous (e.c.) tolerance induction in the prevention of CNS autoimmunity, we utilized an animal model of multiple sclerosis: experimental autoimmune encephalomyelitis (EAE). We show that application of myelin basic protein (MBP) to the skin prior to the induction of EAE by immunization with MBP protected mice from developing disease. In addition, e.c. application of MBP at the first clinical signs of EAE, also resulted in suppression of disease. This therapeutic effect was transferable to naïve recipients with lymph node cells from MBP-treated mice. These regulatory cells were found to be antigen non-specific, as suppression of EAE also occurred when the foreign antigens OVA or TNP were e.c. applied. The mechanistic basis for the tolerance was found to be the production of TGF-beta by the antigen induced toleragenic regulatory T cells. These data demonstrate that e.c.-induced regulatory T cells are potent inhibitors of antigen-specific T cell responses, and suggest that e.c. tolerization may have potential effectiveness in the treatment of autoimmune disorders.

Contrast-enhanced sonographic imaging of lymphatic channels and sentinel lymph nodes

OBJECTIVE

The purpose of this study was to determine whether lymphatic channels (LCs) and sentinel lymph nodes (SLNs) could be detected on sonographic imaging after subcutaneous, submucosal, or parenchymal injections of a sonographic contrast agent (ie, lymphosonography) in a variety of anatomic locations in several animal models.

METHODS

Eight swine, 7 canines, 4 rabbits, and a monkey were used for these evaluations. Gray scale pulse inversion harmonic imaging of the LCs and the SLNs was performed after subcutaneous (n = 58), submucosal (n = 14), or parenchymal (n = 8) injections of a tissue-specific sonographic contrast agent (Sonazoid; GE Healthcare, Oslo, Norway). In many instances, blue dye was injected into the same locations as Sonazoid, and surgical dissection of the SLNs and LCs was performed for comparison. Scanning electron microscopy (SEM) of contrast-enhanced and control lymph nodes from 2 rabbits was performed to determine the mechanism of contrast agent uptake and retention within SLNs.

RESULTS

After subcutaneous, submucosal, or parenchymal contrast agent injections, gray scale pulse inversion harmonic imaging could be used to identify the number and location(s) of LCs and SLNs. After subcutaneous, submucosal, or parenchymal contrast agent injections, Sonazoid was confined to the SLNs (ie, contrast enhancement was not detected in the second-echelon nodes). There was good agreement between the results of lymphosonography and blue dye with surgical dissection in identifying the regional LCs and SLNs. Scanning electron microscopy identified vacuoles representing intact contrast microbubbles within contrast-enhanced SLN macrophages, which were not present in the control lymph nodes.

CONCLUSIONS

Lymphosonography can be used to detect lymphatic drainage pathways and SLNs in a variety of animal models.

Compatibility and stability of dexamethasone sodium phosphate and ketamine hydrochloride subcutaneous infusions in polypropylene syringes

The stability of ketamine hydrochloride injection and dexamethasone sodium phosphate injection, when mixed and stored in polypropylene syringes, was studied. Formulations containing ketamine hydrochloride (50 mg or 600 mg) and dexamethasone sodium phosphate (1 mg) in 0.9% sodium chloride injection (to 14 ml) were prepared and stored at 4 degrees C, 23 degrees C, and 37 degrees C, under normal fluorescent light conditions, for 192 hours. The concentrations of the drugs were determined at 0, 2, 4, 8, 24, 48, 96, and 192 hours using a validated high-pressure liquid chromatography method. The pH, color, and visible particles of each solution were also assessed at each time point. All formulations tested maintained more than 98% of the initial concentrations of both drugs, and no degradation products were detected. The solutions remained clear and colorless and the pH varied within 0.05 units throughout 192 hours. The results indicate that, at the concentrations studied, combinations of ketamine hydrochloride and dexamethasone sodium phosphate in 0.9% sodium chloride injection were physically and chemically stable for at least 192 hours (8 days) when stored in polypropylene syringes.

Controlled transdermal delivery of model drug compounds by MEMS microneedle array

This article reports an in vitro study of microneedle-array-enhanced transdermal transport of model drug compounds dispersed in chitosan films. Each microneedle array has 400 out-of-plane, needle-shaped microstructures fabricated using micro-electro-mechanical systems (MEMS) technology to ensure adequate mechanical strength and high precision, and consistency. A nanometer coating on the microneedles ensured the biocompatibility that is important in the application of transdermal drug delivery. Model drugs selected to investigate skin permeation in vitro were calcein, a small molecule (molecular weight, 623 d) that has little skin penetration, and bovine serum albumin (BSA) (molecular weight, 66,000 d), a hydrophilic biological macromolecule. A Franz permeation cell was used to characterize the permeation rate of calcein and BSA through the rat skin. The transdermal transport behavior of BSA was investigated from solid films coated on the surface of microneedle arrays with various chitosan concentrations, film thicknesses, and BSA contents. The BSA permeation rate decreased with the increase of the chitosan concentration; the thicker the film, the slower the permeation rate. In addition, the permeation rate increased with the increase of BSA loading dose. A linear relationship existed between the permeation rate and the square root of the BSA loading dose. Results showed that the chitosan hydrophilic polymer film acts as a matrix that can regulate the BSA release rate. The controlled delivery of BSA can be achieved using the BSA-containing chitosan matrix film incorporated with the microneedle arrays. This will provide a possible way for the transdermal delivery of macromolecular therapeutic agents such as proteins and vaccines.

[Efficacy of continuous subcutaneous pentazocine infusion for the postoperative analgesia in lower abdominal surgery]

BACKGROUND

Continuous subcutaneous infusion (CSI) of analgesics may be an alternative for pain control in patients without an epidural catheter. The aim of this study was to investigate the efficacy of CSI using pentazocine in lower abdominal surgery with inhalation anesthesia or with total intravenous anesthesia.

METHODS

One hundred forty-seven patients scheduled for gynecological abdominal surgery were analyzed retrospectively. Anesthesia was induced with propofol and was maintained with propofol infusion or isoflurane-nitrous oxide inhalation. All patients received 30-75 mg of pentazocine before incision. At the end of surgery, CSI of pentazocine was begun at a rate of 0.5 ml x hr(-1) x Given regimen was pentazocine 240-390 mg and droperidol 5 mg with 1% lidocaine, and the total amount of dose was 40 ml.

RESULTS

Over 80% of patients were assessed to have effective pain relief and minimum side effects. Patients were classified into two groups by anesthetics during anesthesia; propofol, pentazocine, ketamine group (PPK group, n = 61); nitrous oxide, isoflurane, pentazocine group (GOI group, n=88). There were no differences between the two groups regarding postoperative pain relief, while total dose of pentazocine used during anesthesia were lower in GOI group than PPK group.

CONCLUSIONS

In patients undergoing lower abdominal surgery, CSI of pentazocine provided effective postoperative pain relief and effectiveness did not depend on anesthetics during anesthesia.

Rapid Absorption of Tumescent Lidocaine above the Clavicles: A Prospective Clinical Study

BACKGROUND

Tumescent local anesthesia has been adapted for surgery of the face and neck, but there are no data regarding drug absorption when tumescent injection is used in this region. The aim of this study was to characterize the changes in plasma lidocaine concentrations over time when a tumescent solution is injected into the subcutaneous tissue of the neck. The study was carried out in human volunteer subjects, and injection of lidocaine to the thighs provided control data.

METHODS

Eight healthy female volunteer subjects were studied twice using a prospective, crossover design. Tumescent lidocaine solution was injected into the subcutaneous tissue of the neck in one session and the thighs in another session. The order of injection was randomized. Blood samples were collected for 14 hours after injection, and the plasma concentration of lidocaine measured. The injected solution consisted of lidocaine 0.1%, NaHCO3 12.5 mEq/L, and epinephrine 1:1,000,000 in normal saline. A standardized dose of lidocaine (7 mg/kg) was used for each injection and no surgical procedure was performed.

RESULTS

All subjects completed the study. Subject weight was 66.1 +/- 12.8 kg, body fat was 29.0 +/- 4.7 percent, and body mass index was 23.8 +/- 3.1 kg/m2. The average time to reach peak lidocaine concentration after neck injection was 5.8 hours, whereas peak lidocaine concentration after thigh injection did not occur until 12.0 hours. This difference of 6.2 hours was highly significant (p = 0.009). The average peak concentration after neck injection was 16 percent greater than that after thigh injection (0.94 microg/ml versus 0.81 microg/ml), with the difference approaching significance (p = 0.06). No adverse reactions were noted.

CONCLUSIONS

Tumescent injection above the clavicles results in a rapid rise in plasma lidocaine concentration when compared with injection to the lower extremities. Toxic symptoms could occur much earlier than expected for lower extremity tumescent anesthesia. In addition, dangerous plasma levels could occur if tumescent anesthesia in the lower extremities is followed by tumescent injection above the clavicles, because the absorption curves would be superimposed.

Hypodermoclysis--a victim of historical prejudice

Hypodermoclysis (HDC) had fallen into disrepute after adverse clinical incidents that were obviously the result of improper use of an ingenious technique. HDC has clear advantages over alternative parenteral routes. It has stood the rigour of scientific scrutiny but failed to regain its past glory. This is possibly because of our ignorance and inability to detach ourselves from an age-old prejudice. This is an attempt to demystify some of the myths that surround it. The hope is that older people are not denied an element of health care that they are perhaps most well suited to.

Lipografting: autologous fat grafting for total facial rejuvenation

Surgeons who perform facial rejuvenation procedures have long recognized the importance of volume enhancement. The primary manifestation of aging is loss of subcutaneous tissue, especially the atrophy of fat, which directly contributes to laxity of skin. Autologous fat transplantation has been attempted for over a century with varying degrees of success but more recent techniques have provided more predictable, reproducible, and even permanent results. Fat is an ideal tissue filler substance because it is living tissue and because it is from the patient's own body it is nonallergenic. My technique has evolved over an 11-year period in more than 1800 patients. The procedure can be performed alone as a total facial rejuvenation or in combination with facelift or other facial surgery. The technique requires minimally traumatic fat harvesting, fat preparation, and multilevel facial infiltration. Excess fat not used in the initial procedure is frozen and stored at -16 degrees C and can be used successfully for minor touch-up procedures. Preoperative evaluation of the patient and their understanding of the benefits and limitations of volume restoration surgery is imperative. Structural improvement to the main support areas of the face in the appropriate aesthetic proportions is of prime importance.

Facial recontouring with autogenous fat

Facial fat deflation represents a significant component of facial aging. We discuss and detail preoperative patient selection, fat transfer technique, and potential pitfalls. Fat transfer can reliably improve facial fat deflation and improve facial appearance in the long-term.

A subcutaneous delivery system for the extended release of leuprolide acetate for the treatment of prostate cancer

Following Huggins' original observation of the dependence of the prostate on androgens, testosterone suppression by either orchiectomy or oestrogen compounds (e.g., diethylstilbesterol [DES]) became the standard palliative treatment for advanced prostate cancer. Early studies showed testosterone suppression improved symptoms and patient survival by several months but was not curative. In addition, DES treatment resulted in significant cardiovascular morbidity and mortality from increased thrombotic events. Thus, both orchiectomy and DES were indicated for palliation in late stage disease, but were considered too extreme for earlier stage disease. The discovery of the hypothalamic peptide, luteinising hormone releasing hormone (LHRH), and its stimulatory release of luteinising hormone (LH) from the pituitary gland led to the synthesis of LHRH analogues (i.e., hormone therapy). LHRH analogues (e.g., leuprolide acetate) desensitise and downregulate pituitary LHRH receptors, thus reducing LH synthesis and release. The reduced release, in turn, decreases testosterone levels to those observed in DES-treated and orchiectomised patients. In contrast, LHRH analogues do not increase cardiovascular events. Therefore, leuprolide acetate therapy has been adopted as a safer alternative to DES and is considered to be generally reversible. This increased safety has allowed LHRH therapy to be applied in earlier stage prostate cancer. Recent studies have shown decreased rates of biochemical failure and a potential for increased patient survival with hormone therapy in conjunction with radical prostatectomy or radiation therapy. This article will focus on the literature supporting early, adjuvant LHRH therapy and Eligard 7.5 mg, a new depot formulation of leuprolide acetate that uses the Atrigel drug delivery system, causing an increase in bioavailability and optimising testosterone suppression - two key features of depot hormone suppression.

Past 10-year status of insulin therapy for preschool-age Japanese children with type 1 diabetes

The aim of this study was to evaluate the past 10-year status of insulin therapy for preschool-age children with type 1 diabetes in Japan. One-hundred and forty-two patients who had been diagnosed at less than 5 years of age within the past 10 years (1993-2002) at 36 hospitals were registered in this study on April 2003. The methods of daily insulin therapy and episodes of severe hypoglycemia during the preschool period were investigated. Eighty-six (60.6%) children were treated with a pen-type device and 56 (39.4%) were treated with a syringe-type device. The once-a-day insulin regimen was used for 2, a twice-a-day regimen for 104, a three-times-a-day for 28 and a four-times-a-day for 8. Episodes of severe hypoglycemia were recorded in nearly half of the subjects, and one-fourth of the subjects had repeated episodes. One hundred and eleven of their parents were questioned regarding the degree of psychosocial stress experienced during the care of their children. Most parents worried about the glycosylated hemoglobin value at each hospital visit. They were next very afraid of nocturnal severe hypoglycemia, independent of any actual experience. These results suggest that although insulin therapy can involve various methods, the important point is to simultaneously provide good glycemic control and prevent severe hypoglycemia, especially during this age.

In Vitro and In Vivo Characterization of MEMS Microneedles

Transdermal drug delivery TDD systems have many advantages but are conventionally limited by the low permeability of skin. The idea of using microneedles to painlessly penetrate the topmost impermeable stratum corneum has previously been put forward. In this paper, the fabrication of solid and hollow silicon microneedles with straight side-walls and with the following dimensions: 20-100 microm in diameter and 100-150 microm in length is described. In vitro tests demonstrate that with prior solid microneedle application, transdermal drug transport is significantly increased by 10-20 times, with the degree of enhancement being related to needle diameter. In vivo tests in diabetic animals, however, were unable to demonstrate any delivery of insulin through the hollow microneedles. It is proposed that two factors, microneedle length and tip sharpness, have to be improved for systemic drug delivery to be seen in vivo.

The "pain pen" for breakthrough cancer pain: a promising treatment

Breakthrough pain has been recognized as a challenging pain phenomenon in cancer. Oral transmucosal fentanyl citrate (OTFC) recently has been recommended as treatment, but OTFC is not widely available. Therefore, alternatives are needed. In two separate pilot studies, 58 patients were instructed to self-administer subcutaneous (SC) rescue opioids (hydromorphone (n=43), morphine (n=11), or sufentanil (n=4), using a standard injection-pen for breakthrough pain. Patients were asked to rate the overall efficacy of SC rescue opioids on a 3-point scale (not noticeable, moderate, or good). The efficacy was rated as good in 49 patients (84%, 95% CI: 73-91%), moderate in 8 patients (14%), and not noticeable in 1 patient (2%). The median dose per injection was equianalgesic to 25 mg of SC morphine (range: 4-150 mg). Twenty-nine patients (50%) were treated until death (n=26) or were on ongoing treatment (n=3). Patients were treated for a median of 6 weeks (1 day-41 months).

Comparison of systemic exposure to nemifitide following two methods of subcutaneous administration to healthy volunteers

The purpose of this study was to evaluate the safety and pharmacokinetics of nemifitide, a synthetic antidepressant pentapeptide, following its subcutaneous (s.c.) administration by standard needle injection or by a needle-free (Biojecttrade mark) injection and to compare these two routes of administration for systemic exposure. This small-scale, randomized, single-dose, parallel design, open-label pilot study consisted of three treatment groups of four subjects each dosed as follows: group 1: 40 mg of nemifitide administered by standard needle/syringe and groups 2 and 3: 40 and 80 mg nemifitide, respectively, administered by using a needle-free (Bioject injection delivery system. Plasma concentrations of nemifitide were determined by LC/MS/MS in blood samples collected at 10 min and 0.5, 1, 2, 4, 6 and 24 h after dosing. PK parameters, including observed C(max), T(max) and AUC(0-24), were calculated and statistical analysis of the data was conducted. Safety assessments (dosing site evaluations) were done at 0.5, 1, 5 and 24 h after dosing. Vital signs and clinical laboratory tests were taken on day 1 prior to dosing and at 24 h post-dose. Adverse experiences in all subjects were observed only as drug-related local reactions at the injection sites. All were considered mild in severity and transient (resolved by 24 h after dosing). T(max) was observed at 10 min after dose and was the same in all subjects. In the three dosing groups, 1 (40 mg), 2 (40 mg) and 3 (80 mg), observed C(max) values were 226, 245 and 440 ng/ml, respectively, and AUC(0-24) values were 108, 106 and 205 ng.h/ml, respectively. Ratios of AUC(0-24) and observed C(max) for nemifitide in plasma between groups 1 and 2 were within the 80%-125% range, indicating that the two modes of drug administration resulted in similar systemic exposure to nemifitide. Pharmacokinetic parameters (AUC(0-24) and C(max)) indicate dose-proportionality between the doses of 40 and 80 mg.

Consensus recommendations on the use of botulinum toxin type a in facial aesthetics

The use of botulinum toxin type A for facial enhancement is the most common cosmetic procedure currently undertaken in the United States. Overall clinical and study experience with botulinum toxin type A treatment for facial enhancement has confirmed that it is effective and safe in both the short and long term. Nevertheless, consistent guidelines representing the consensus of experts for aesthetic treatments of areas other than glabellar lines have not been published. Therefore, a panel of experts on the aesthetic uses of Botox Cosmetic (botulinum toxin type A; Allergan, Inc., Irvine, Calif.) was convened to develop consensus guidelines. This publication comprises the recommendations of this panel and provides guidelines on general issues, such as the importance of the aesthetic evaluation and individualization of treatment, reconstitution and handling of the botulinum toxin type A, procedural considerations, dosing and injection-site variables, and patient selection and counseling. In addition, specific considerations and recommendations are provided by treatment area, including glabellar lines, horizontal forehead lines, "crow's feet," "bunny lines" (downward radiating lines on the sides of nose), the perioral area, the dimpled chin, and platysmal bands. The review of each area encompasses the relevant anatomy, specifics on injection locations and techniques, starting doses (total and per injection point), the influence of other variables, such as gender, and assessment and retreatment issues. Factors unique to each area are presented, and the discussion of each treatment area concludes with a review of key elements that can increase the likelihood of a successful outcome. Summary tables are provided throughout.