II. Needle phobia: a psychological perspective

Rational approach to the prescription of anti-rheumatic drugs in rheumatoid arthritis: a product leaflet-based strategy in Italy

The treatment of patients with rheumatoid arthritis (RA) has dramatically changed in the past 30 years. Currently, numerous conventional, biologic, and targeted synthetic DMARDs have been licensed and used following recommendations provided by international and national scientific societies. However, the availability of biosimilars and the increasing necessity of savings impacted on the local/national prescription of these drugs. The information provided by data sheet of every single drug is a decisive factor on the choice of a certain treatment merged with the patient's profile. Thus, our purpose was to construct a rational algorithm for the treatment strategy in RA according to costs and the product leaflet of the biologic and targeted-synthetic DMARDs currently licensed in Italy. We used the most recent available recommendations and then we performed a review of the literature considering all the factors that are known to influence drug safety/effectiveness. All these factors were considered in the context of the data sheets of currently available originators and biosimilars.

Fear of Needles and Seasonal Influenza Vaccine Acceptance Amongst Adults in the United Arab Emirates: A Cross-Sectional Study and Implications for Nursing

Introduction

Seasonal influenza remains a challenge in the United Arab Emirates, and vaccination is an important preventive measure. However, fear of needles may be an obstacle in vaccination efforts.

Objective

The purpose of this study was to determine, in a non-clinical sample obtained from the UAE, how much of an impact fear of needles has on the decision to receive the seasonal influenza vaccine.

Methods

In the period September-December 2022, 372 participants were surveyed on their willingness to be vaccinated, their level of vaccine knowledge, and their level of fear of needles. Logistic regression models were used to assess the impact of fear of needles and vaccine knowledge on the decision to accept the seasonal influenza vaccine.

Results

Fear of needles and vaccine knowledge are significant predictors in the decision to receive the vaccine. There were no gender or ethnic differences in fear of needles, but there were differences in the decision to receive the vaccines, with women and non-Arabs being more hesitant.

Conclusion

Fear of needles may be an important variable to account for in public policies designed to improve vaccination rates in the UAE. For public health policy in the UAE, this implies that authorities must dedicate efforts to manage fear of needles in the general population. Efforts to address fear of vaccines in the general population must be made with proper training of nurses. Alternatively, authorities may need to seek oral alternatives for the administration of the seasonal influenza vaccine.

Acoustic stimulation for relieving pain during venipuncture: a systematic review and network meta-analysis

OBJECTIVES

To assess whether acoustic stimulations relieve venipuncture pain and determine which stimulation is the most effective type.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

PubMed, Cochrane Central Register of Controlled Trials, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov and the International Clinical Trials Registry Platform databases were systematically searched in September 2023.

STUDY SELECTION

Randomised controlled trials evaluating the efficacy of acoustic stimulations on patients undergoing venipuncture were eligible. Acoustic stimulations were classified into seven categories: five types of acoustic stimulations (music medicine (researcher selected), music medicine (patient selected), music therapy, sounds with linguistic meaning and sounds without linguistic meaning) and two controls (only wearing headphones and no treatment).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included self-reported pain intensity assessed during venipuncture and treatment cost, and secondary outcomes were self-reported mental distress and adverse events.

RESULTS

Of 6406 citations, this network meta-analysis included 27 studies including 3416 participants; the mean age was 31.5 years, and 57% were men. Among the five types of acoustic stimulations, only musical interventions, such as music medicine (patient selected) (standardised mean difference (SMD) -0.44 (95% CI: -0.84 to -0.03); low confidence), music medicine (researcher selected) (SMD -0.76 (95% CI: -1.10 to -0.42); low confidence) and music therapy (SMD -0.79 (95% CI: -1.44 to -0.14); low confidence), were associated with improved pain relief during venipuncture compared with no treatment. No significant differences existed between the types of acoustic stimulations. Free-of-charge acoustic stimulations were provided to patients, and no specific adverse events were reported. In many studies, the risk of bias was rated high because of the difficulty of blinding the intervention to the participants and the self-reported pain outcome.

CONCLUSIONS

Music interventions were associated with reduced venipuncture pain. Comparisons between types of acoustic stimulations revealed no significant differences. Therefore, music intervention could be a safe and inexpensive pain relief method for venipuncture.

PROSPERO REGISTRATION NUMBER

CRD42022303852.

Dialysis Needle-Related Distress: Patient Perspectives on Identification, Prevention, and Management

Introduction

Needle-related distress is common among people receiving hemodialysis and affects quality of life and treatment decisions, yet little evidence exists to guide management. This study explored patients' experiences of needle-related distress to inform the development of prevention, identification, and management strategies.

Methods

Semistructured interviews concerning dialysis cannulation, needle-related distress, and potential solutions were conducted with people with current or recent experience of hemodialysis (N = 15) from a tertiary hospital-based service. Interviews ceased at thematic saturation. Transcripts were analyzed thematically.

Results

There were 4 themes and 11 subthemes generated: (i) uncovering a hidden source of distress (dismissal and minimization by others; suffering in silence to stay alive; preparation, assessment, and education); (ii) coping with cannulation pain and trauma (interaction between physical damage, pain, and distress; operator dependency-the importance of nurse skill and technique); (iii) the environment created by dialysis nurses (emotional transference; communication during cannulation; valuing empathy and person-centered care; a psychosocially supportive dialysis unit); and (iv) supporting patient self-management of distress (accessing tools to help themselves; distraction to reduce distress).

Conclusion

Needle-related distress is an often-hidden element of the hemodialysis experience. Patients learn to tolerate it as an inevitable part of dialysis for survival. Nurses' technical skills and the dialysis environment they create are key determinants of the patient cannulation experience. Proposed solutions include psychological screening, education for patients to self-manage distress, and training for nurses in communication and providing relevant psychological support.

Nephrology nurses' perspectives working with patients experiencing needle-related distress

BACKGROUND

A key skill of nephrology nursing is cannulation of patients receiving haemodialysis. Traumatic and unsuccessful cannulation experiences, particularly in the initial weeks of haemodialysis, may contribute to the onset of needle distress for patients.

OBJECTIVES

To identify the key knowledge, skills and attitudes of nephrology nurses working with haemodialysis patients and the competencies relevant to nephrology nursing working with patients with needle-related distress.

DESIGN

A qualitative study involving semistructured interviews. Interviews were audio-recorded, transcribed and deductive, and inductive thematic analysis applied.

PARTICIPANTS

Nephrology nurses (n = 17) were interviewed from a tertiary kidney service in South Australia. Nurses had varying roles and years of experience (range 1-30 years) working with dialysis patients within the service.

RESULTS

Two overarching themes, (1) Flexibility in Practice and Care and (2) Responsibility of Nephrology Nursing, were identified as relevant across all knowledge, skills and attitudes of nephrology nurses working with patients with needle-related distress. Thirty-six knowledge, skills and attitudes were identified; 12 related to knowledge, 14 related to skills and 10 were identified as attitudes and were summarised under seven broad competencies.

CONCLUSION

This study identifies potential knowledge, skills and attitudes and competencies required for nephrology nurses working with patients with needle-related distress. It highlights strategies that may prevent the onset and worsening of needle-related distress, as well as reduce it. It also brings to light that nurses desire additional education regarding strategies to improve the patient experience of cannulation and nurse confidence and skill in this area.

Age regression in the treatment of needle phobia: a case report

Trypanophobia (needle phobia) frequently occurs because of negative encounters with medical procedures and/or needles. Trypanophobia ranges in severity from causing mild anxiety, including apprehension about medical procedures, to severe anxiety and complete avoidance of medical care. In this case report, we describe a 29-year-old who underwent hypnosis-facilitated age regression therapy to improve his trypanophobia. Through the guidance of his subconscious, he realized his reaction to needles may not have been directly related to a difficult medical procedure he had undergone at the age of two. The patient's subconscious turned his attention to the anxiety he felt from being separated from his mother at the time of the procedure.

The use of cellulose, chitosan and hyaluronic acid in transdermal therapeutic management of obesity: A review

Obesity is a clinical condition with rising popularity and detrimental impacts on human health. According to the World Health Organization, obesity is the sixth most common cause of death worldwide. It is challenging to combat obesity because medications that are successful in the clinical investigation have harmful side effects when administered orally. The conventional approaches for treating obesity primarily entail synthetic compounds and surgical techniques but possess severe adverse effects and recurrences. As a result, a safe and effective strategy to combat obesity must be initiated. Recent studies have shown that biological macromolecules of the carbohydrate class, such as cellulose, hyaluronic acid, and chitosan, can enhance the release and efficacy of medications for obesity but due to their short biological half-lives and poor oral bioavailability, their distribution rate is affected. This helps to comprehend the need for an effective therapeutic approach via a transdermal drug delivery system. This review focuses on the transdermal administration, utilizing cellulose, chitosan, and hyaluronic acid via microneedles, as it offers a promising solution to overcome existing therapy limitations in managing obesity and it also highlights how microneedles can effectively deliver therapeutic substances through the skin's outer layer, bypassing pain receptors and specifically targeting adipose tissue.

Experimental Elucidation of Templated Crystallization and Secondary Processing of Peptides

The crystallization of peptides offers a sustainable and inexpensive alternative to the purification process. In this study, diglycine was crystallised in porous silica, showing the porous templates' positive yet discriminating effect. The diglycine induction time was reduced by five-fold and three-fold upon crystallising in the presence of silica with pore sizes of 6 nm and 10 nm, respectively. The diglycine induction time had a direct relationship with the silica pore size. The stable form (α-form) of diglycine was crystallised in the presence of porous silica, with the diglycine crystals obtained associated with the silica particles. Further, we studied the mechanical properties of diglycine tablets for their tabletability, compactability, and compressibility. The mechanical properties of the diglycine tablets were similar to those of pure MCC, even with the presence of diglycine crystals in the tablets. The diffusion studies of the tablets using the dialysis membrane presented an extended release of diglycine through the dialysis membrane, confirming that the peptide crystal can be used for oral formulation. Hence, the crystallization of peptides preserved their mechanical and pharmacological properties. More data on different peptides can help us produce oral formulation peptides faster than usual.

Hyperkalemia in a Hemolyzed Sample in Pediatric Patients: Repeat or Do Not Repeat?

OBJECTIVE

The aim of the study is to analyze whether repeat testing is necessary in healthy children presenting to a pediatric emergency department (ED) who are found to have hyperkalemia on a hemolyzed specimen.

METHODS

A 5-year retrospective analysis of pediatric ED patients found to have elevated potassium values on laboratory testing of a sample reported to be hemolyzed. All patients aged 0 to 17 years who had an elevated potassium level after an intravenous draw resulted from a serum sample that was reported as hemolyzed during an ED visit were included in the study.

RESULTS

One hundred eighty-seven patients with some degree of both hemolysis and hyperkalemia were included in the final analysis. The median age was 1.9 years of age. The most common race among all patients was White, followed by African American, and Asian. One hundred forty-five children had repeat sampling for hemolyzed hyperkalemia, 142 children, 97.9% (95% confidence interval, 95.6%-100%) had a normal potassium on repeat and 3 children, 2.1% (95% confidence interval, 0.0%-4.4%) had true hyperkalemia. The frequency of true hyperkalemia in our study population was 2% (3/145). All 3 of these patients had underlying conditions that would appropriately have raised clinician suspicion for hyperkalemia.

CONCLUSIONS

It may be unnecessary to obtain repeat samples to confirm normal potassium in a hemolyzed sample with normal blood urea nitrogen and creatinine.

A Narrative Review on Non-Invasive Drug Delivery of Teriparatide: A Ray of Hope

In the field of pharmaceutical biotechnology and formulation development, various protein and peptide-based drugs have been used for therapeutic and clinical implications. These are mainly given via parenteral routes like intravenous, subcutaneous or intramuscular delivery. Teriparatide, also known as PTH 1-34, is a U.S. Food & Drug Administartion-approved anabolic drug to treat osteoporosis is currently available in market only as subcutaneous injection. The quest for elimination of needle in case of given peptidal delivery to replace it with alternative routes like nasal, buccal, transdermal and pulmonary pathways has driven meticulous drug research. The pharmaceutical scientists are working on innovation and approaches involving new materials and methods to develop the formulations for protein and peptides by noninvasive routes. Lately, various approaches have been carried out which involve many strategies and technologies to deliver teriparatide via alternative routes. But, physicochemical instability, proteolytic degradation, low bioavailability, etc. are some obstacles to develop suitable delivery system for teriparatide. This review intends to gather the overall developments in delivery systems specific to teriparatide which meant for better convenience and avoids vulnerability of multiple subcutaneous injections. In addition, the article emphasizes on the successes to develop noninvasive technologies and devices, and new milestones for teriparatide delivery.

Potential of Nuclear Imaging Techniques to Study the Oral Delivery of Peptides

Peptides are small biomolecules known to stimulate or inhibit important functions in the human body. The clinical use of peptides by oral delivery, however, is very limited due to their sensitive structure and physiological barriers present in the gastrointestinal tract. These barriers can be overcome with chemical and mechanical approaches protease inhibitors, permeation enhancers, and polymeric encapsulation. Studying the success of these approaches pre-clinically with imaging techniques such as fluorescence imaging (IVIS) and optical microscopy is difficult due to the lack of in-depth penetration. In comparison, nuclear imaging provides a better platform to observe the gastrointestinal transit and quantitative distribution of radiolabeled peptides. This review provides a brief background on the oral delivery of peptides and states examples from the literature on how nuclear imaging can help to observe and analyze the gastrointestinal transit of oral peptides. The review connects the fields of peptide delivery and nuclear medicine in an interdisciplinary way to potentially overcome the challenges faced during the study of oral peptide formulations.

Experimental Validation of Diffraction Lithography for Fabrication of Solid Microneedles

Microneedles are highly sought after for medicinal and cosmetic applications. However, the current manufacturing process for microneedles remains complicated, hindering its applicability to a broader variety of applications. As diffraction lithography has been recently reported as a simple method for fabricating solid microneedles, this paper presents the experimental validation of the use of ultraviolet light diffraction to control the liquid-to-solid transition of photosensitive resin to define the microneedle shape. The shapes of the resultant microneedles were investigated utilizing the primary experimental parameters including the photopattern size, ultraviolet light intensity, and the exposure time. Our fabrication results indicated that the fabricated microneedles became taller and larger in general when the experimental parameters were increased. Additionally, our investigation revealed four unique crosslinked resin morphologies during the first growth of the microneedle: microlens, first harmonic, first bell-tip, and second harmonic shapes. Additionally, by tilting the light exposure direction, a novel inclined microneedle array was fabricated for the first time. The fabricated microneedles were characterized with skin insertion and force-displacement tests. This experimental study enables the shapes and mechanical properties of the microneedles to be predicted in advance for mass production and wide practical use for biomedical or cosmetic applications.

Potential of Microneedle Systems for COVID-19 Vaccination: Current Trends and Challenges

To prevent the coronavirus disease 2019 (COVID-19) pandemic and aid restoration to prepandemic normality, global mass vaccination is urgently needed. Inducing herd immunity through mass vaccination has proven to be a highly effective strategy for preventing the spread of many infectious diseases, which protects the most vulnerable population groups that are unable to develop immunity, such as people with immunodeficiencies or weakened immune systems due to underlying medical or debilitating conditions. In achieving global outreach, the maintenance of the vaccine potency, transportation, and needle waste generation become major issues. Moreover, needle phobia and vaccine hesitancy act as hurdles to successful mass vaccination. The use of dissolvable microneedles for COVID-19 vaccination could act as a major paradigm shift in attaining the desired goal to vaccinate billions in the shortest time possible. In addressing these points, we discuss the potential of the use of dissolvable microneedles for COVID-19 vaccination based on the current literature.

Biocompatible All-in-One Adhesive Needle-Free Cup Patch for Enhancing Transdermal Drug Delivery

Patch-type drug delivery has garnered increased attention as an attractive alternative to the existing drug delivery techniques. Thus far, needle phobia and efficient drug delivery remain huge challenges. To address the issue of needle phobia and enhance drug delivery, we developed a needle-free and self-adhesive microcup patch that can be loaded with an ultrathin salmon DNA (SDNA) drug carrier film. This physically integrated system can facilitate efficient skin penetration of drugs loaded into the microcup patch. The system consists of three main components, namely, a cup that acts as a drug reservoir, an adhesive system that attaches the patch to the skin, and physical stimulants that can be used to increase the efficiency of drug delivery. In addition, an ultrathin SDNA/drug film allows the retention of the drug in the cup and its efficient release by dissolution in the presence of moisture. This latter feature has been validated using gelatin as a skin mimic. The cup design itself has been validated by comparing its deformation and displacement with those of a cylindrical structure. Integration of the self-adhesive microcup patch with both ultrasonic waves and an electric current allows the model drug to penetrate the stratum corneum of the skin barrier and the whole epidermis, thereby enhancing transdermal drug delivery and reducing skin irritation. This system can be used as a wearable biomedical device for efficient transdermal and needle-free drug delivery.

Comparative evaluation of pain perception with a new needle-free system and dental needle method in children: a randomized clinical trial

Background

Pain control during dental procedures is one of the most important topics related to behavior management in children. This study aims to compare the pain perception associated with a needle-free system (Comfort-In™) and the dental needle method during filling and pulpotomy treatments in children.

Methods

The study included teeth that required treatment (pulpotomy or filling treatment) in 56 patients aged 4 to 11 years with no systemic problems or history of allergy. Patients were randomly divided into the needle-free system group (filling treatment, n = 13; pulpotomy, n = 15) and dental needle method group (filling treatment, n = 14; pulpotomy, n = 14). For pulpotomy and filling treatment performed with 0.3 mL anesthesia, the active ingredient of which is 2% lidocaine and 1/80000 epinephrine. The patients’ behavior before the procedure was evaluated by a pediatric dentist using the Frankl Behavior Scale. The pain intensity was assessed Immediately after injection (induction), during treatment (treatment), and at the end of the treatment (post treatment) by the Wong-Baker Faces Pain Scale.

Results

The median (IQR-InterQuartile Range) induction pain value was 6[3-8] and 2[0-4] in dental needle method and needle-free system respectively, p < 0.001). In filling and pulpotomy treatment group, no difference between the needle and needle-free group for treatment and post-treatment pain values.

Conclusions

For pulpotomy and filling treatment, needle-free system performed with 0.3 mL anesthesia was found as effective as infiltrative anesthesia with a dental needle method.

Trial registration

ClinicalTrials.gov, NCT04653974. Registered 4 December 2020 – Retrospectively registered.

Transdermal Drug Delivery Systems and Their Use in Obesity Treatment

Transdermal drug delivery (TDD) has recently emerged as an effective alternative to oral and injection administration because of its less invasiveness, low rejection rate, and excellent ease of administration. TDD has made an important contribution to medical practice such as diabetes, hemorrhoids, arthritis, migraine, and schizophrenia treatment, but has yet to fully achieve its potential in the treatment of obesity. Obesity has reached epidemic proportions globally and posed a significant threat to human health. Various approaches, including oral and injection administration have widely been used in clinical setting for obesity treatment. However, these traditional options remain ineffective and inconvenient, and carry risks of adverse effects. Therefore, alternative and advanced drug delivery strategies with higher efficacy and less toxicity such as TDD are urgently required for obesity treatment. This review summarizes current TDD technology, and the main anti-obesity drug delivery system. This review also provides insights into various anti-obesity drugs under study with a focus on the recent developments of TDD system for enhanced anti-obesity drug delivery. Although most of presented studies stay in animal stage, the application of TDD in anti-obesity drugs would have a significant impact on bringing safe and effective therapies to obese patients in the future.

Development of an orally delivered GLP-1 receptor agonist through peptide engineering and drug delivery to treat chronic disease

Peptide therapeutics are increasingly used in the treatment of disease, but their administration by injection reduces patient compliance and convenience, especially for chronic diseases. Thus, oral administration of a peptide therapeutic represents a significant advance in medicine, but is challenged by gastrointestinal instability and ineffective uptake into the circulation. Here, we have used glucagon-like peptide-1 (GLP-1) as a model peptide therapeutic for treating obesity-linked type 2 diabetes, a common chronic disease. We describe a comprehensive multidisciplinary approach leading to the development of MEDI7219, a GLP-1 receptor agonist (GLP-1RA) specifically engineered for oral delivery. Sites of protease/peptidase vulnerabilities in GLP-1 were removed by amino acid substitution and the peptide backbone was bis-lipidated to promote MEDI7219 reversible plasma protein binding without affecting potency. A combination of sodium chenodeoxycholate and propyl gallate was used to enhance bioavailability of MEDI7219 at the site of maximal gastrointestinal absorption, targeted by enteric-coated tablets. This synergistic approach resulted in MEDI7219 bioavailability of ~ 6% in dogs receiving oral tablets. In a dog model of obesity and insulin resistance, MEDI7219 oral tablets significantly decreased food intake, body weight and glucose excursions, validating the approach. This novel approach to the development of MEDI7219 provides a template for the development of other oral peptide therapeutics.

Coolsense® versus EMLA® for peripheral venous cannulation in adult volunteers: A randomised crossover trial

Peripheral venous cannulation (PVC) is a commonly performed invasive medical procedure. Topical treatments such as the eutectic mixture of local anaesthetics (EMLA®, Aspen Pharmacare Australia Pty Ltd, St Leonards, NSW) attenuate the associated pain, but are limited by requiring up to one hour of application before becoming effective. The Coolsense® (Coolsense Medical Ltd., Tel Aviv, Israel) pain numbing applicator is a new device using a cryoanalgesic means to anaesthetise skin within seconds. Coolsense is being increasingly used for cannulation, but comparative studies are lacking. We recruited 64 healthy adult volunteers to this open-label two sequence, two period randomised crossover trial. Participants had two 20 gauge venous cannulae inserted, one on the dorsum of each hand. Each cannulation attempt was preceded by treatment with Coolsense or an EMLA patch containing 2.5% lidocaine and 2.5% prilocaine. The primary outcome was participant pain using the 0-10 numerical pain rating scale. Secondary outcomes were participant satisfaction scores on a 0-10 scale, treatment preference, and failed cannulation attempts. Participants were randomly assigned to either the Coolsense EMLA (n = 32) or EMLA Coolsense (n = 32) sequence. All participants completed the trial. The pooled mean paired difference of the numerical pain rating scale was -1.84 (95% confidence intervals -1.28 to -2.41; P < 0.001) in favour of EMLA. The pooled mean paired difference for satisfaction score was 2.26 (95% confidence intervals 1.46 to 3.07; P < 0.001) higher with EMLA. Most participants preferred EMLA over Coolsense (P < 0.001). There was no significant difference regarding failed cannulation between the two treatments (P = 0.14). Among healthy individuals undergoing elective PVC, EMLA was associated with reduced pain, increased satisfaction, and was the preferred treatment compared to Coolsense.

The Children's Action-Reaction Assessment Tool (CARAT) as an observational technique for assessing symptom management: An initial validation study with children aged 3-7 years undergoing needle procedures

PURPOSE

For many children, needle procedures are fearful events that are often painful. The first step in symptom management is to assess the child's pain and fear, and the next step is to use coping strategies to provide symptom relief for children who experience or feel pain and fear during procedures. The Children's Action-Reaction Assessment Tool (CARAT) is built on action-reaction strategies. This study aimed to determine the inter-rater reliability of the CARAT when used during needle procedures with 3- to 7-year-old children. DESIGN AND METHODS: We used a quantitative approach in which 21 children were observed by two independent observers during needle procedures to evaluate the inter-rater reliability of the CARAT. Data were analysed with descriptive statistics, and the observation scores were calculated with an intraclass correlation coefficient (ICC) test on SPSS for Windows, version 25.

RESULTS

The completed CARAT indicated the use of action-reaction strategies. Neither action nor reaction strategies were frequently used. The parents were seldom involved in the procedure. The inter-rater reliability showed a sufficient correlation between the observers. PRACTICE IMPLICATIONS: This study showed promising results for the inter-rater reliability of the CARAT, which can be used to facilitate care for children. The observational tool can be used to assess the use of action-reaction strategies in conjunction with needle procedures in children aged 3-7 years.

Ultrasonic actuation of a fine-needle improves biopsy yield

Despite the ubiquitous use over the past 150 years, the functions of the current medical needle are facilitated only by mechanical shear and cutting by the needle tip, i.e. the lancet. In this study, we demonstrate how nonlinear ultrasonics (NLU) extends the functionality of the medical needle far beyond its present capability. The NLU actions were found to be localized to the proximity of the needle tip, the SonoLancet, but the effects extend to several millimeters from the physical needle boundary. The observed nonlinear phenomena, transient cavitation, fluid streams, translation of micro- and nanoparticles and atomization, were quantitatively characterized. In the fine-needle biopsy application, the SonoLancet contributed to obtaining tissue cores with an increase in tissue yield by 3–6× in different tissue types compared to conventional needle biopsy technique using the same 21G needle. In conclusion, the SonoLancet could be of interest to several other medical applications, including drug or gene delivery, cell modulation, and minimally invasive surgical procedures.

A microneedle platform for buccal macromolecule delivery

Alternative means for drug delivery are needed to facilitate drug adherence and administration. Microneedles (MNs) have been previously investigated transdermally for drug delivery. To date, drug loading into MNs has been limited by drug solubility in the polymeric blend. We designed a highly drug-loaded MN patch to deliver macromolecules and applied it to the buccal area, which allows for faster delivery than the skin. We successfully delivered 1-mg payloads of human insulin and human growth hormone to the buccal cavity of swine within 30 s. In addition, we conducted a trial in 100 healthy volunteers to assess potential discomfort associated with MNs when applied in the oral cavity, identifying the hard palate as the preferred application site. We envisage that MN patches applied on buccal surfaces could increase medication adherence and facilitate the painless delivery of biologics and other drugs to many, especially for the pediatric and elderly populations.

Nursing process for a patient with needle phobia: a case study

OBJECTIVES

to report a clinical case of needle phobia which culminated in cardiac arrest and describe the outcome of a care plan based on fear and anxiety diagnoses, using the Roy adaptation model as the framework.

METHODS

case study conducted in a chemotherapy outpatient unit in Rio de Janeiro. Care was guided by the nursing process and the use of instruments to assess the venous network, anxiety and fear.

RESULTS

the Roy adaptation model enabled proposing nursing interventions that allowed the study subject to adapt to the external and internal stimuli triggered by vasovagal syndrome. The instruments indicated the choice of an adequate semi-implanted venous access device and led to improved levels of anxiety and fear.

FINAL CONSIDERATIONS

after carrying out the nursing activities, anxiety was reduced, and the patient achieved greater control over fear.

Effect of a Vibratory Anesthetic Device on Pain Anticipation and Subsequent Pain Perception Among Patients Undergoing Cutaneous Cancer Removal Surgery: A Randomized Clinical Trial

Importance

Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient's perception of procedural pain.

Objective

To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score ≤4).

Design, Setting, and Participants

Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis.

Interventions

Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode.

Main Outcomes and Measures

Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score).

Results

A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03).

Conclusions and Relevance

This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not.

Level of Evidence

2.

Trial Registration

ClinicalTrials.gov identifier: NCT03467685.

A conceptual framework for understanding iatrophobia

OBJECTIVE

Iatrophobia - fear of doctors, medical care, or the medical care system - is common among patients and can negatively impact their health-seeking behaviors and relationships with health care professionals. Despite this, academic literature on iatrophobia often fails to explore its nuanced causes.

METHODS

We establish a conceptual framework of iatrophobia, categorizing sources of fear that may create barriers to accessing medical care, and recommend a research agenda to address this phenomenon and understand its role in medical care.

RESULTS

The framework includes three categories of determinants of iatrophobia: patient fear of illness and the medical exam, patient fear of physician reaction, and patient fear related to barriers to care. These categories represent influences from individual to more system-related factors associated with the physician-patient relationship. Research examining iatrophobia should focus on understanding its prevalence, how patients cope with their fear, discussing iatrophobia in the physician-patient encounter, the sociopolitical contribution to iatrophobia, and how iatrophobia can be reduced.

CONCLUSIONS

Iatrophobia can be categorized into three primary domains, but it remains poorly understood.

PRACTICE IMPLICATIONS

A more thorough understanding of iatrophobia will help to contextualize its role amid other barriers to care and patient health outcomes.

Medical procedures in children using a conceptual framework that keeps a focus on human dimensions of care - a discussion paper

Purpose: Children’s perspectives in the context of health service delivery have historically been seen as unimportant. They have been viewed as unintelligent, unable to effectively share or tell of their experiences or fully participate in their care, potentially resulting in a sense of dehumanisation.

Method: The present paper illustrates children’s experiences when undergoing medical procedures, using application of the eight dimensions of humanised care theoretical framework.

Results: Findings from six published papers were reflectively interrogated to identify implicit findings related to the dimensions of humanised care. These implicit findings show ways of caring for childrenwhichcan lead to enhanced human sensitivity in care or conversely where the dimensions of being human are obscured to greater or lesser degrees and can result in forms of dehumanisation.

Conclusions: Inadvertent dehumanising features of practice can be mediated by encouraging the inclusion of children’s own lifeworld perspective and make room for their voices in both care and research. In this way the present well documented power imbalance could be addressed. Adding the value of the theoretical framework highlights areas of need for young children to be cared for as human beings.

Single Versus Double Tourniquet Technique for Ultrasound-Guided Venous Catheter Placement

Introduction

Peripheral, ultrasound-guided intravenous (IV) access occurs frequently in the emergency department, but certain populations present unique challenges for successfully completing this procedure. Prior research has demonstrated decreased compressibility under double tourniquet technique (DT) compared with single tourniquet (ST). We hypothesized that catheters inserted under DT method would have a higher first-stick success rate compared with those inserted under ST method.

Methods

We randomized 100 patients with a history of difficult IV access, as defined by past ultrasound IV, prior emergency visit with two or more attempts required for vascular access, history of IV drug abuse, history of end stage renal disease on hemodialysis or obesity, to ultrasound-guided IV placement under either DT or ST method. We measured the vein characteristics measured under ultrasound, and recorded the number of attempts and location of attempts at vascular access.

Results

Of an initial 100 patients enrolled, we analyzed a total of 99 with 48 placed under ST and 51 placed under DT. Attending physicians inserted 41.7% of ST and 41.2% of DT, with non-attending inserters (including residents, nurses, and technicians) inserted the remainder. First-stick success rate was observed at 64.3% in ST and 66.7% in DT (p=0.93). Attendings had an overall higher first-stick success rate (95.1%) compared to non-attending inserters (65.5%) (p=<0.001). The average vein depth measured in ST was 0.73 centimeters (cm) compared with 0.87 cm in DT (p=0.02).

Conclusion

DT technique did not produce a measureable increase in first-stick success rate compared to ST, including after adjusting for level of training of inserter. However, a significant difference in average vein depth between the study arms may have limited the reliability of our overall results. Future studies controlling for this variable may be required to more accurately compare these two techniques.

Epidermal micro-perforation potentiates the efficacy of epicutaneous vaccination

The skin is an immune organ comprised of a large network of antigen-presenting cells such as dendritic cells, making it an attractive target for the development of new vaccines and immunotherapies. Recently, we developed a new innovative and non-invasive vaccination method without adjuvant based on epicutaneous vaccine patches on which antigen forms a dry deposit. Here we describe in mice a method for potentiating the efficacy of our epicutaneous vaccination approach using a minimally invasive and epidermis-limited skin preparation based on laser-induced micro-perforation. Our results showed that epidermal micro-perforation increased trans-epidermal water loss, resulting in an enhancement of antigen solubilization from the surface of the patch, and increased the quantity of antigen delivered to the epidermis. Importantly, this was not associated with an increase in systemic passage of the antigen. Skin micro-perforation slightly activated keratinocytes without inducing an excessive level of local inflammation. Moreover, epidermal micro-perforation improved antigen capture by epidermal dendritic cells and specifically increased the level of Langerhans cells activation. Finally, we observed that epidermal micro-perforation significantly increased the level of the specific antibody response induced by our epicutaneous Pertussis vaccine candidate containing non-adsorbed recombinant Pertussis Toxin and reduced the amount of antigen dose required. Overall, these data confirm the benefit of a minimal and controlled epidermal preparation for improving the effectiveness of an epicutaneous patch-based vaccine, without adversely affecting the safety of the method.

The fear of needles: A systematic review and meta-analysis

AIMS

The aim of this study was to evaluate the prevalence of needle fear and summarize the characteristics of individuals who exhibit this fear.

BACKGROUND

Injections are among the most common medical procedures, yet fear of needles can result in avoidance of preventive measures and treatment.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (1966-2017), Embase (1947-2017), PsycINFO (1967-2017), and CINAHL (1961-2017) were searched, with no restrictions by age, gender, race, language, or country.

REVIEW METHODS

The prevalence of needle fear was calculated and restricted maximum likelihood random effects models were used for meta-analysis and meta-regression.

RESULTS

The search yielded 119 original research articles which are included in this review, of which 35 contained sufficient information for meta-analysis. The majority of children exhibited needle fear, while prevalence estimates for needle fear ranged from 20-50% in adolescents and 20-30% in young adults. In general, needle fear decreased with increasing age. Both needle fear and needle phobia were more prevalent in females than males. Avoidance of influenza vaccination because of needle fear occurred in 16% of adult patients, 27% of hospital employees, 18% of workers at long-term care facilities, and 8% of healthcare workers at hospitals. Needle fear was common when undergoing venipuncture, blood donation, and in those with chronic conditions requiring injection.

CONCLUSIONS

Fear of needles is common in patients requiring preventive care and in those undergoing treatment. Greater attention should be directed to interventions which alleviate fear in high-risk groups.

Current status of selected oral peptide technologies in advanced preclinical development and in clinical trials

The development of oral dosage forms that allows absorption of therapeutic peptides to the systemic circulation is one of the greatest challenges for the pharmaceutical industry. Currently, a number of technologies including either mixtures of penetration enhancers or protease inhibitors and/or nanotechnology-based products are under clinical development. Typically, these formulations are presented in the form of enteric-coated tablets or capsules. Systems undergoing preclinical investigation include further advances in nanotechnology, including intestinal microneedle patches, as well as their combination with regional delivery to the colon. This review critically examines four selected promising oral peptide technologies at preclinical stage and the twelve that have progressed to clinical trials, as indicated in www.clinicaltrials.gov. We examined these technologies under the criteria of peptide selection, formulation design, system components and excipients, intestinal mechanism of action, efficacy in man, and safety issues. The conclusion is that most of the technologies in clinical trials are incremental rather than paradigm-shifting and that even the more clinically advanced oral peptide drugs examples of oral bioavailability appear to yield oral bioavailability values of only 1-2% and are, therefore, only currently suitable for a limited range of peptides.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

INTRODUCTION

Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency.

METHODS AND ANALYSIS

We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule.

ETHICS AND DISSEMINATION

The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used.

TRIAL REGISTRATION NUMBER

ACTRN12615000588594; Pre-results.

Dexamethasone Delivery by an Implant-Mediated Drug Delivery System in the Canine Mandible

BACKGROUND

A newly introduced implant-mediated drug delivery system (IMDDS) showed promising results in a rabbit tibia model. The aim of the present study is to evaluate whether dexamethasone administered by the IMDDS has sustained effects in the canine mandible - a different anatomic location, in a different species.

METHODS

IMDDS was installed at the mesial root of the second premolar site in the mandibles of six beagle dogs. After complete healing, 10 mg dexamethasone was administered through the IMDDS. The same amount of drug was administered to five control animals by intramuscular injection. The release pattern was monitored for 2 weeks by measuring plasma drug concentrations.

RESULTS

A sustained plasma dexamethasone concentration was detected after a peak at 6 hours until the end of the observation period, despite individual variations. The concentration was lower than reported in the rabbit tibia model. In contrast, plasma concentration of the control group showed an early peak at 2 hours and decreased rapidly.

CONCLUSION

Dexamethasone was effectively released from the IMDDS for a prolonged time in the canine mandible model.

Assessment of acceptability and usability of new delivery prototype device for intradermal vaccination in healthy subjects

The objectives of this study were to assess the acceptability and usability of a newly developed intradermal prototype device, VAX-ID™, in healthy subjects. In April 2012 an investigational study was conducted in healthy subjects aged 18 to 65 y. To compare injection site and route of administration, subjects were allocated to 4 subgroups, either receiving subsequently 2 intradermal (ID) injections (one in the forearm and one in the deltoid) or an ID (forearm) and an intramuscular (IM) (deltoid) injection. All injections contained saline solution. Acceptability was assessed with a subjects' questionnaire and a daily electronic diary for 5 d. Usability was assessed with a vaccinators' questionnaire and an expert panel. A 10-point Visual Analog Scale was used to score several statements on usability and acceptability. A total of 102 healthy subjects were enrolled in the study (age: 19-63). No statistically significant differences were seen in demographic characteristics between the ID and IM groups. Anxiety before injection, pain during injection and duration of injection were rated significantly lower for ID compared to IM. One day after the injections, redness was reported more often after ID injection in the forearm versus ID in the deltoid; pain at injection site was reported significantly more often after IM vs. ID injection. The new VAX-ID prototype device was found easy to handle, easy to use and safe. The new VAX-ID prototype device was shown to have a high degree of acceptability as well as usability. Further studies with VAX-ID will be conducted using vaccine antigen allowing assessment of immunogenicity and safety. Additionally, these studies will help to further improve VAX-ID in terms of accuracy of delivered dose and feedback to the vaccinator. (NCT01963338).