Interventions for Individuals With High Levels of Needle Fear: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

Non-pharmacological interventions to reduce procedural needle pain in children (6-12 years): A systematic review

PROBLEM

Children of different age groups frequently undergo painful procedures involving needles, which can be a source of significant discomfort. Regrettably, this aspect of care often receives insufficient attention from healthcare professionals. The existing literature proposes several methodologies for managing procedural pain, with nonpharmacological techniques being particularly promising. These techniques should be adapted to the patient's age, but literature predominantly emphasizes their use with infants. Thus, it is necessary to evaluate their effectiveness in diverse age groups. Consequently, the purpose of this systematic review is to identify non-pharmacological interventions used to prevent needle-related procedural pain in children (age group 6-12 years).

ELIGIBILITY CRITERIA

Primary studies in English language on non-pharmacological interventions in children aged 6-12 years undergoing needle-related procedures found on PubMed, CINAHL and Embase.

SAMPLE

A total of 18 studies were included.

RESULTS

The results indicate the potential application of various non-pharmacological techniques, with distraction methods standing out. These techniques include activities like utilizing cards, watching cartoons, employing virtual reality and playing video games.

CONCLUSIONS

Children's procedural pain represents a significant challenge in treatment plans. Literature offers several approaches, including nonpharmacologic methods, to control this problem. Prioritizing procedural pain management is critical both at clinical and organizational levels to improve the quality of pediatric care.

IMPLICATIONS

These findings offer different options to support clinical practice, holding the potential to enhance the quality of patient care.

Observational Behavioral Coding in the Pediatric Emergency Department: Development of the Emergency Department Child Behavior Coding System

BACKGROUND

Despite improvements over the past decade, children continue to experience significant pain and distress surrounding invasive procedures in the emergency department (ED). To assess the impact of newly developed interventions, we must create more reliable and valid behavioral assessment tools that have been validated for the unique settings of pediatric EDs.

OBJECTIVE

This study aimed to create and test the Emergency Department Child Behavior Coding System (ED-CBCS) for the assessment of child distress and nondistress behaviors surrounding pediatric ED procedures.

METHODS

Via an iterative process, a multidisciplinary expert panel developed the ED-CBCS, an advanced time-based behavioral coding measure. Inter-rater reliability and concurrent validity were examined using 38 videos of children aged from 2 to 12 years undergoing laceration procedures. Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were used to examine concurrent validity.

RESULTS

The final ED-CBCS included 27 child distress and nondistress behaviors. Time-unit κ values from 0.64 to 0.98 and event alignment κ values from 0.62 to 1.00 indicated good to excellent inter-rater reliability for all but one of the individual codes. ED-CBCS distress (B = 1.26; p < 0.001) and nondistress behaviors (B = -0.69, p = 0.025) were independently significantly associated with FLACC scores, indicating concurrent validity.

CONCLUSIONS

We developed a psychometrically sound tool tailored for pediatric ED procedures. Future work could use this measure to better identify behavioral targets and test the effects of interventions to relieve pediatric ED pain and distress.

Prevalence, factors associated and management of needle phobia among the general population in Saudi Arabia and Egypt

OBJECTIVE

This study aims to assess the prevalence of needle phobia among Saudi and Egyptian adult populations. In addition, underlying causes and strategies that can be utilized to address needle fear were investigated.

METHODS

A cross-sectional online survey study was conducted in Saudi Arabia and Egypt between 1 May and 30 June 2023. Participants aged 18 years and above and living in Saudi Arabia and Egypt were eligible to complete the survey. Participants were invited to participate in this study through social media platforms (Facebook, X, Snapchat, and Instagram). A convenience sampling technique was used to recruit the study participants. A 21-item questionnaire consisting of four sections including a Likert scale score was used to answer the research objectives. Numeric data were presented as mean ± SD. For categorical variables, percentages were used. Comparison between groups were made by Student's t-test or Mann Whitney test according to data distribution. Chi squared tests for categorical values were conducted. A binary logistic regression analysis was conducted to investigate factors associated with needle phobia.

RESULTS

A total of 4065 participants were involved in this study (Saudi Arabia: 2628 and Egypt: 1437). Around one-third of the study participants (36.5%) confirmed that they have needle phobia. Most of the study participants (81.1%) reported that they have had needle phobia since they were under 18 years of age. Pain, general anxiety, and fear of making a mistake during the procedure were the most commonly reported contributors for fear of needles during or before a medical procedure. Around 15.8% of the study participants reported that they have tried to get rid of phobia from needles. Non-surgical alternatives (such as oral medications and patches) and using smaller/thinner needles were the most commonly reported interventions that reduced fear of needles. Binary logistic regression analysis identified that females, those who are aged (41-50 years), widowed, those with bachelor's degrees and higher education, and those unemployed were more likely to have needle phobia compared to others.

CONCLUSION

Our study highlighted the high prevalence of needle fear within an adult population in Egypt and Saudi Arabia. Females, those who are aged (41-50 years), those widowed, those with higher education degrees, those unemployed, those working in the health sector and people with low income were more likely to have needle phobia compared to others.

If we know better, why don't we do better? A rapid quality improvement project to increase utilization of comfort measures to reduce pain and distress in children in a COVID-19 mass vaccination clinic

INTRODUCTION

Many evidence-based tools exist to address pain and distress associated with injections; however, there remains a large gap between the knowledge of these tools and their utilization. Our hospital began a quality improvement (QI) project prior to COVID-19, with the goal of increasing the utilization of Comfort Promise measures during needle procedures. When COVID-19 vaccinations were approved, our mass vaccination clinics provided an opportunity to rapidly increase utilization across the institution. The primary aim was to increase the percentage of comfort measures (CM) offered with COVID-19 vaccinations.

METHODS

Through this QI project, nurses and other professionals implemented CMs during COVID mass vaccination clinics. Clinics occurred in 3 age-based waves. Waves served as Plan-Do-Study-Act (PDSA) cycles. Families completed post-vaccination surveys to determine what CMs were offered and intention for future use with vaccinations.

RESULTS

Uptake of CMs (PainEase, ShotBlockers, Comfort Positioning, Alternative Focus, Topical Lidocaine, and Breastfeeding/Sucrose) throughout the waves increased and generally remained stable. CMs also seemed to decrease pain/distress with vaccinations (70.5 to 88.7%), and children/caregivers intended to use some combination for future vaccinations (82.5 to 98.5%).

CONCLUSIONS

Fast-paced mass vaccination clinics provided an ideal opportunity to significantly increase utilization of CMs. Across age groups CMs yielded high satisfaction and interest in future utilization. Clinic nurses returned to their own sub-specialties and became change agents.

IMPLICATIONS

If all healthcare providers can work together to achieve consensus while incorporating comfort measures into daily practice, sustained change with incorporation of these evidence-based tools can be achieved. Future directions are discussed.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study

BACKGROUND

Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure.

OBJECTIVE

We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals.

METHODS

We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus.

RESULTS

Parents rated their child's difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo's strong ease of use and high acceptability. In the exit survey, parents rated their child's fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=-4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child's fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game's interactive design, as observed in 69% (24/35) of our participants.

CONCLUSIONS

The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children's fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern.

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.

Picturing Bravery: A Rapid Review of Needle Procedures Depicted in Children's Picture Books

Existing research has identified evidence-based strategies for mitigating fear and pain during needle procedures; yet, families often experience limited access to health professionals who deliver these interventions. Children may benefit from learning about such strategies in a developmentally appropriate and accessible format such as a picture book. This review aimed to summarize content related to needle procedures represented in picture books for 5- to 8-year-old children. Key terms were searched on Amazon, and the website was used to screen for relevant eligibility criteria. Three levels of screening and exclusions resulted in a final sample of 48 books. Quantitative content analysis was used to apply a coding scheme developed based on relevant Clinical Practice Guidelines and systematic reviews. Cohen's Kappa indicated strong reliability, and frequencies were calculated to summarize the content. The books were published between 1981 and 2022. All 48 books included at least one evidence-based coping strategy. Distressing aspects such as scary visuals were often included (27.1%), as well as specific expressions of fear (52.1%) and pain (16.7%). Overall, this study paves the way for researchers interested in evaluating the effectiveness of picture books on children's knowledge and self-efficacy, as well as creating interventions for coping.

Nurses' understanding and management of iron deficiency in Australia: a cross-sectional, exploratory study

OBJECTIVES

To assess the experiences and knowledge of nurses in the area of iron deficiency.

DESIGN

A cross-sectional, exploratory study using online survey.

SETTING

Data were collected from nurses working at various primary, secondary and tertiary Australian health practices and organisations.

PARTICIPANTS

Australian nurses currently in practice.

METHOD

Australian nurses currently in practice were invited to complete an online survey about their work background, personal experiences with iron deficiency and iron-deficiency identification and treatment. The survey included a nine-item questionnaire to assess knowledge of iron-deficiency risk factors and biochemistry.

RESULTS

A total of 534 eligible nurses participated in the survey. Participants were more likely to be female, aged 55-64 years, and working in general practice. Just under half (45.1%) reported being diagnosed with iron deficiency themselves. Unusual fatigue or tiredness was the most frequent symptom that alerted nurses to potential iron deficiency in patients (reported by 91.9% of nurses). Nurses who had participated in formal training around iron deficiency in the last 5 years demonstrated a significantly higher knowledge score (4.2±2.1) compared with those who had not or were not sure about their formal training status (3.7±1.9, p=0.035). Knowledge around the understanding of functional iron deficiency was limited.

CONCLUSIONS

Nurses report personal experiences of iron deficiency and show good knowledge of symptoms, demonstrating the potential for them to take a leading role in managing iron deficiency in patients. Educational programmes are required to address knowledge gaps and should be offered via various methods to accommodate a diverse nurse cohort. Our research highlights the potential for an expanded scope of practice for nurses in the primary care setting in the area of iron deficiency.

Appropriate procedures to increase the adherence of children to blood collection: A cross-sectional study

Background and Aim

Venipuncture for blood collection elicits fear and pain in children. We investigated factors that affect satisfaction with health checkups that included blood collection in healthy 7-8-year-old children who underwent blood collection with topical anesthesia.

Method

Two studies, one questionnaire survey, and the other structured interviews were conducted to gather insights and understand the emotions of 492 and 20 children, respectively.

Results

We found that the following six points can be applied to encourage children to assess their experience of blood collection positively: (1) prior information using a pamphlet; (2) telling the children that the volume of blood drawn will be small; (3) carefully explaining the risk and benefit of topical anesthesia; (4) conducting the blood collection process swiftly; (5) praising and thanking the children's effort and cooperation; and (6) explaining the results of the research to the children if their blood is going to be used for research.

Conclusion

The findings indicate that with appropriate measures to reduce pain and fear, children's initial negative feelings toward blood collection can be replaced by positive feelings after the procedure.

COVID-19 vaccines associated with vasovagal malaise: A retrospective study in two mass vaccination centers and analysis of the WHO pharmacovigilance database

The association between COVID-19 vaccines and vasovagal malaise (VVM) has recently been reported in the literature. Our study aimed to describe COVID-19 vaccines associated VVM cases and to identify risk factors of COVID-19 vaccines associated VVM. To this end, we performed a descriptive study of VVM reports associated with COVID-19 vaccines from two French mass COVID-19 vaccination centers. We also extracted reports of VVM associated with all-COVID-19 vaccines in VigiBase®, the World Health Organization (WHO) pharmacovigilance database to analyze demographic data. In the two French mass vaccination center database, 408 entries reported VVM after the standard administration of tozinameran - Pfizer® (1.63/1,000 vaccinated persons). Of these cases, 213 (52.2%) occurred in women, and 193 (47.3%) occurred in the 18-29 year-old (yo) age group. In 232 cases (56.8%), patients had a history of anxiety related to needles or medical visits, 213 (52.2%) reported a fear of COVID-19 vaccination in particular, and 233 (57.1%) had a history of VVM. In VigiBase®, 336,291 notifications of COVID-19 vaccines associated with VVM were identified in the adult population during the period of analysis. The most reported age class was 18-44 years (52.4%), and women represented 71.7% of the reports. Reporting widely differed depending on the country. This study, performed in real-life conditions, highlights that VVM is associated with all-COVID-19 vaccines. Young age and history of anxiety related in young adults could be a triggering factor of vaccines-associated VVM. Further studies are needed to confirm our results.

Nonuptake of HIV Testing Among Transgender Populations in the United States: Results from the 2015 U.S. Transgender Survey

Purpose

In this study, we examined the nonuptake of HIV testing and the main reasons for never testing among transgender populations.

Methods

Data on 26,927 respondents from the 2015 U.S. Transgender Survey were analyzed in this study. The main reasons for never testing were categorized as low risk perception; access related; fear or HIV-related stigma; and others. We performed weighted descriptive statistics and multivariable logistic regression analyses, controlling for sociodemographic characteristics and sexual orientation.

Results

Forty-five percent of the respondents had never tested for HIV. Trans women (adjusted odds ratio [aOR]=1.1, 95% confidence interval [CI]=1.07-1.25) and assigned female at birth genderqueer/nonbinary individuals (AFAB GQ/NB) (aOR=1.3, 95% CI=1.16-1.35) had significantly higher odds of reporting never testing for HIV compared with trans men. The most reported reason for never testing was low risk perception (87%). AFAB GQ/NB (aOR=1.4, 95% CI=1.22-1.66) had significantly higher odds of reporting low risk perception as the main reason for never testing for HIV relative to trans men. AFAB GQ/NB were less likely to report access related as the main reason for never testing (aOR=0.8, 95% CI=0.56-0.95). The odds of trans women and assigned male at birth GQ/NB individuals reporting fear or HIV-related stigma as the main reason for never testing were 1.7 (95% CI=1.13-2.55) and 2.8 (95% CI=1.69-4.70) times that of trans men. Both trans women (aOR=0.8, 95% CI=0.65-0.97) and AFAB GQ/NB (aOR=0.7, 95% CI=0.60-0.88) had lower odds of reporting others. The main reasons for never testing also varied by sociodemographic factors, including age, educational attainment, race/ethnicity, employment status, poverty, and sexual orientation.

Conclusions

HIV testing is suboptimal among transgender populations. Our findings also suggest that barriers to HIV testing vary by transgender populations, thus interventions for improved uptake should be population specific.

Improving management of needle distress during the journey to dialysis through psychological education and training-the INJECT study feasibility pilot protocol

BACKGROUND

Needle-related distress is a common yet poorly recognised and managed problem among haemodialysis (HD) patients. The aim of this pilot study is to test the feasibility and acceptability of the INJECT Intervention-an innovative psychology-based intervention to empower patients to self-manage needle distress with the support of dialysis nurses.

METHODS

This investigator-initiated, single-arm, non-randomised feasibility study will take place in a large dialysis service in Adelaide, Australia. Participants will include patients aged ≥ 18 years, commencing or already receiving maintenance HD, recruited through dialysis physicians and nursing staff as individuals believed to be at risk of needle distress. They will be screened for inclusion using the Dialysis Fear of Injection Questionnaire (DFIQ) and enrolled into the study if the score is ≥ 2. The multi-pronged intervention encompasses (i) psychologist review, (ii) patient self-management program and (iii) nursing education program. The primary aim is to evaluate feasibility and acceptability of the intervention from patient and dialysis nurse perspectives, including recruitment, retention, engagement with the intervention and completion. Secondary exploratory outcomes will assess suitability of various tools for measuring needle distress, evaluate acceptability of the nursing education program and measure cannulation-related trauma and vascular access outcomes.

CONCLUSION

The results will inform the protocol for larger trials addressing needle distress in HD patients.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000229875, approved 4 April 2021, https://www.anzctr.org.au/ .

Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol

OBJECTIVE

Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia.

METHODS

This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol.

RESULTS

Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times.

CONCLUSIONS

The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.

Gonadotropin-releasing hormone analog therapies for children with central precocious puberty in the United States

Gonadotropin-releasing hormone agonists (GnRHa's) are the standard treatment for children with central precocious puberty (CPP). We aim to present data on available GnRHa options with an easy-to-review table and discuss factors that influence treatment selection. Five GnRHa's are currently FDA-approved and prescribed in the US and published data suggest similar safety and efficacy profiles over the first year of treatment. One- and 3-month intramuscular (IM) leuprolide acetate (LA) have long-term safety and efficacy data and allow for flexible dosing. Six-month IM triptorelin pamoate offers a longer duration of treatment, but without long-term efficacy and outcome data. Six-month subcutaneous (SQ) LA combines a SQ route of injection and long duration of action but lacks long-term efficacy and outcome data. The 12-month SQ histrelin acetate implant avoids injections and offers the longest duration of action, but requires a minor surgical procedure with local or general anesthesia. Factors in treatment selection include route of administration, needle size, injection volume, duration of action, and cost. The current GnRHa landscape provides options with varying benefits and risks, allowing physicians and caregivers to select the most appropriate therapy based on the specific needs and concerns of the child and the caregiver. Agents have different advantages and disadvantages for use, with no one agent displaying superiority.

Combined Fainting and Psychogenic Non-epileptic Seizures as Significant Therapy Hurdles in Blood-Injury-Injection Phobia: A Mini-Review and Case Report

BACKGROUND

Anxiety disorders are the most frequent mental disorders. Among the different subtypes, specific phobias are the commonest. Due to the ongoing SARS-CoV-19 pandemic, blood-injury-injection phobia (BII) has gained wider attention in the context of large-scale vaccination campaigns and public health. In this BII phobia mini-review and case report, we describe the successful treatment of a severe BII phobia case with combined fainting and psychogenic non-epileptic seizures (PNES) and demonstrate the role of specialized outpatient care.

CASE REPORT

The patient was a 28-year-old woman. She suffered from intense fear and recurrent fainting with regard to needles, injections, injuries, and at the sight of blood since early childhood. Medical history revealed infrequent events suggestive of PNES following panic attacks after sustained exposure to phobic stimuli. Family history was positive for circulation problems and BII fears. Psychopathological evaluation confirmed BII phobia symptoms and diagnosis was made according to the DSM-5. The Multidimensional Blood/Injury Phobia Inventory short version (MBPI-K) revealed severe manifestation of the disease. Neurological examination was ordinary. Repeated electroencephalography detected no epileptic pattern. Cranial magnetic resonance imaging showed normal morphology. Treatment was carried out by a seasoned, multidisciplinary team. Cognitive behavior therapy and exposure were performed. Modification of standard treatment protocol was necessary due to hurdles posed by recurrent fainting and a severe panic-triggered dissociative PNES during in vivo exposure. Modification was implemented by limiting in vivo exposure intensity to moderate anxiety levels. In addition to applied muscle tension and ventilation techniques, increased psychoeducation, cognitive restructuring, and distress tolerance skills (e.g., ice pack, verbal self-instructions) were used to strengthen the patient's situational control during in vivo exposure. A total of 15 sessions were performed. Therapy success was proven by 83% reduction in MBPI-K rating, SARS-CoV-19 vaccination, and a blood draw without psychological assistance, fainting, or seizure.

CONCLUSION

Taken together, this case demonstrates the potential of and need for specialized outpatient care and individualized treatment for severe BII phobia patients in order to provide them the perspective to have necessary medical procedures done and get vaccinated.

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.

The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management

The clinical construct of "anxiety neurosis" was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM-III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive-behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

COVID-19 vaccine platforms: Delivering on a promise?

The emergence of the novel SARS-CoV-2 and COVID-19 has brought into sharp focus the need for a vaccine to prevent this disease. Vaccines have saved millions of lives since their introduction to the public over 200 years ago. The potential for vaccination reached new heights in the mid-20th century with the development of technologies that expanded the ability to create novel vaccines. Since then, there has been continued technological advancement in vaccine development. The resulting platforms provide the promise for solutions for many infectious diseases, including those that have been with us for decades as well as those just now emerging. Each vaccine platform represents a different technology with a unique set of advantages and challenges, especially when considering manufacturing. Therefore, it is essential to understand each platform as a separate product and process with its specific quality considerations. This review outlines the relevant platforms for developing a vaccine for SARS-CoV-2 and discusses the advantages and disadvantages of each.

Multi-Electrode Array of Sensory Neurons as an In Vitro Platform to Identify the Nociceptive Response to Pharmaceutical Buffer Systems of Injectable Biologics

PURPOSE

Pharmaceutical buffer systems, especially for injectable biologics such as monoclonal antibodies, are an important component of successful FDA-approved medications. Clinical studies indicate that buffer components may be contributing factors for increased injection site pain.

METHODS

To determine the potential nociceptive effects of clinically relevant buffer systems, we developed an in vitro multi-electrode array (MEA) based recording system of rodent dorsal root ganglia (DRG) sensory neuron cell culture. This system monitors sensory neuron activity/firing as a surrogate of nociception when challenged with buffer components used in formulating monoclonal antibodies and other injectable biologics.

RESULTS

We show that citrate salt and citrate mannitol buffer systems cause an increase in mean firing rate, burst frequency, and burst duration in DRG sensory neurons, unlike histidine or saline buffer systems at the same pH value. Lowering the concentration of citrate leads to a lower firing intensity of DRG sensory neurons.

CONCLUSION

Increased activity/firing of DRG sensory neurons has been suggested as a key feature underlying nociception. Our results support the utility of an in vitro MEA assay with cultured DRG sensory neurons to probe the nociceptive potential of clinically relevant buffer components used in injectable biologics.

The prevalence and evidence-based management of needle fear in adults with chronic disease: A scoping review

Background

Little is known about the prevalence and best management of needle fear in adults with chronic disease, who may experience frequent and long-term exposure to needles for lifesaving therapies such as renal dialysis and cancer treatment. Identifying interventions that assist in management of needle fear and associated distress is essential to support these patients with repeated needle and cannula exposure.

Method

We followed the PRISMA methodology for scoping reviews and systematically searched PsychINFO, PubMed (MEDLINE), ProQuest, Embase and grey literature and reference lists between 1989 and October 2020 for articles related to needle discomfort, distress, anxiety, fear or phobia. The following chronic diseases were included: arthritis, asthma, chronic back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental illness, or kidney failure. Literature concerning dentistry, vaccination, intravenous drug users and paediatric populations were excluded.

Results

We identified 32 papers reporting prevalence (n = 24), management (n = 5) or both (n = 3). Needle fear prevalence varied in disease cohorts: 17–52% (cancer), 25–47% (chronic kidney disease) and 0.2–80% (diabetes). Assessment methods varied across studies. Management strategies had poor evidence-base, but included needle-specific education, decorated devices, cognitive-behavioural stress management techniques, distraction, and changing the therapy environment or modality.

Conclusion

Although needle fear is common there is a paucity of evidence regarding interventions to address it among adults living with chronic disease. This scoping review has highlighted the need for improved identification of needle fear in adults and development of interventions are required for these cohorts.

Self-injectable extended release formulation of Remdesivir (SelfExRem): A potential formulation alternative for COVID-19 treatment

There has been a growing and evolving research to find a treatment or a prevention against coronavirus 2019 (COVID-19). Though mass vaccination will certainly help in reducing number of COVID-19 patients, an effective therapeutic measure must be available too. Intravenous remdesivir (RDV) was the first drug receiving Food and Drug Administration (FDA) approval for the treatment of COVID-19. However, in a pandemic like COVID-19, it is essential that drug formulations are readily available, affordable and convenient to administer to every patient around the globe. In this study, we have developed a Self-injectable extended release subcutaneous injection of Remdesivir (SelfExRem) for the treatment of COVID-19. As opposed to intravenous injection, extended release subcutaneous injection has the benefits of reducing face-to-face contact, minimizing hospitalization, reducing dosing frequency and reducing overall health care cost. SelfExRem was developed using a biodegradable polymer, poly(lactic-co-glycolic acid) (PLGA), dissolved in a biocompatible vehicle. Six different batches were formulated using 2 different grades of low molecular weight PLGA and 3 different PLGA concentration. The force of injection of various polymeric solutions through 23–30-gauge needles were analyzed using a TA.XTplus texture analyzer. The time required for injection was evaluated both manually and by using an autoinjector. In vitro release of all the batches were carried out in 1% v/v tween 80 in phosphate buffer saline. The study indicated that SelfExRem developed with 15% w/v PLGA (75:25) provided a steady release of drug for 48 h and may be a breakthrough approach for the treatment of COVID-19.

Oral delivery of metformin by chitosan nanoparticles for polycystic kidney disease

Nanoparticle drug delivery has many advantages over small molecule therapeutics, including reducing off-target side effects and increasing drug potency. However, many nanoparticles are administered parenterally, which is challenging for chronic diseases such as polycystic kidney disease (PKD), the most common hereditary disease worldwide in which patients need continuous treatment over decades. To address this clinical need, we present the development of nanoparticles synthesized from chitosan, a widely available polymer chosen for its ability to improve oral bioavailability. Specifically, we optimized the synthesis parameters of chitosan nanoparticles and demonstrate mucoadhesion and permeation across an intestinal barrier model in vitro. Furthermore, when administered orally to mice, ex vivo imaging of rhodamine-loaded chitosan nanoparticles showed significantly higher accumulation in the intestines compared to the free model drug, as well as 1.3 times higher serum area under the curve (AUC), demonstrating controlled release and improved serum delivery over 24 h. To test its utility for chronic diseases such as PKD, we loaded the candidate PKD drug, metformin, into chitosan nanoparticles, and upon oral administration to a PKD murine model (Pkd1fl/fl;Pax8-rtTA;Tet-O cre), a lower cyst burden was observed compared to free metformin, and was well tolerated upon repeated dosages. Blood urea nitrogen (BUN) and creatinine levels were similar to untreated mice, demonstrating kidney and biocompatibility health. Our study builds upon previous chitosan-based drug delivery approaches, and demonstrates a novel, oral nanoformulation for PKD.

Feasibility of one-session treatment for specific needle phobia in an adult IAPT service – a case series

One-session treatment for specific phobias (OST; Öst, 2012) has been found to be efficient and effective in reducing the severity of phobia in an adult population. This study aimed to investigate the feasibility of OST in an Improving Access to Psychological Therapy (IAPT) primary care service in the North East of England. Participants were four women and one man between the ages of 21 and 46 years; all presented with needle phobia. Treatment consisted of three clinical contacts: a 1-hour pre-treatment interview to identify the catastrophic belief centred on the phobic situation; a 2.5–3-hour treatment session using exposure in vivo (i.e. images, videos and handling of a syringe – no actual injections) and participant modelling in accordance with OST protocol; and a 30-minute follow-up telephone appointment. Outcome was measured with standard IAPT and additional psychometrics, as well as qualitative client feedback. The outcome suggests the application of OST to be effective for needle phobia, as well as feasible and cost- and resource-efficient in its application to an IAPT primary care service. Further research needs to investigate its effects in comparison with multiple single sessions of cognitive behavioural therapy in an adult population, as well as appropriate outcome measures to suit an IAPT application.

Key learning aims

(1)

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.

Children still experience pain during hospital stay: a cross-sectional study from four countries in Europe

BACKGROUND

Little is known whether children experience pain during hospital stay from the child's own perspective or not. The existing studies tend to be based on a small number of children and therefore have limitations concerning the generalisability of the results.

AIM

The aim of this study was to describe children's self-reported pain and experience concerning pain management during hospital stay.

METHODS

This study has a quantitative cross-sectional design with descriptive statistics as data analysis.

RESULTS

A total of 786 questionnaires, Pain in Children in Hospital, were distributed in four countries with the response rate of 75% which was almost equal between countries. Our result showed that 87% (503/579) children at hospital self-reported pain during the past 24 h. Nearly 63% of the children reported a pain score of > 5 the last 24 h. Most of children reported that they had received a question about pain from the hospital staff, and that the staff observed and assessed their pain. Totally 95% reported that they were satisfied with their pain relief during the last 24 h.

CONCLUSION

Our study showed that when children were given the possibility to self-report pain, nearly 2/3 expressed that they had experienced pain during hospital stay. However, most of them reported satisfaction with pain management and their pain relief.

Public knowledge and attitude toward lumbar puncture among adults in Riyadh, Saudi Arabia: A cross-sectional study

Objective:

The aim of this study is to evaluate knowledge of and attitudes toward the lumbar puncture procedure among adults in Riyadh region, Saudi Arabia, 2018.

Methods:

This study used a quantitative cross-sectional evaluation of the responses of adults aged ⩾18 years from the Saudi Telecom Company database in the Riyadh region of Saudi Arabia to an online survey between October and December 2018. The questionnaire included questions on knowledge, attitudes, and demography. The questionnaire was pretested and validated (Cronbach’s alpha = 0.701).

Results:

Of 1500 questionnaires, 1223 (81.5%) were returned and included in the analysis. In the study, 57.7% of the participants were aged 18–25 years, and 58.5% of the participants were females. Only 235 (19.2%) participants had an accepted knowledge level of lumbar puncture. The attitudes of the majority of the participants (n = 1151, 94%) to lumbar puncture were acceptable. A multivariate logistic regression test revealed a significant association between an acceptable knowledge level and acceptable attitude level (odds ratio = 2.30, 95% confidence interval = 1.06–5.66). A significant association was also found with ages over 46 years old (odds ratio = 12.99, 95% confidence interval = 4.45–37.9). The attitudes level toward lumbar puncture had a significant negative association among the participants who had a fear of injections in the lumbar region (odds ratio = 0.46, 95% confidence interval = 0.3–0.68).

Conclusion:

There is a lack of appropriate knowledge of the lumbar puncture procedure among the public which predict an unacceptable attitude toward lumbar puncture. Improvements in public education could improve public awareness of the clinical importance/value and complications of lumbar puncture.

Characterization of skin blebs from intradermal jet injection: Ex-vivo studies

This paper presents results from an ex-vivo study of intradermal jet injections, which is an attractive method to achieve both needle-free and fractional dose delivery of vaccines. Due to the fact that fluid properties of many novel therapeutics and vaccines can vary significantly, a key parameter for our study is the fluid viscosity, whilst the main focus is on determining the best correlation between the delivered volume and geometrical dimensions of the fluid deposit. For this we use a combination of top-view (skin wheal), underside (below the dermis), and cross-section (true skin bleb) perspectives and find that the top-view alone, as done in clinical practice, is insufficient to estimate the volume deposited in the dermis. Overall, the best correlation is found between the injection volume and cross-sectional diameter, however there is significant variation amongst the different fluids. For mean injection volumes of 60 μL the mean bleb diameter is ≈8 mm, with mean aspect ratio h¯/d=0.38, indicating the blebs are mostly oblate. However, the shape varies with viscosity and the higher viscosity does not spread laterally to the same degree as lower viscosity fluids. In addition, our high-speed video observations of the injection process, reveal some interesting dynamics of the jet injection method, and we modeled the bleb growth with an exponential saturation.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.

Painless injections-a possibility with low level laser therapy

Background

Dental procedures commonly involve the injection of local anesthetic agents, which causes apprehension in patients. The objective of dental practice is to provide painless treatment to the patient. The purpose of this study was to evaluate the effect of Low Level Laser Therapy (LLLT) in reducing the pain due to local anesthetic injection.

Materials and Methods

A prospective, split-mouth study was conducted on 25 patients. In Condition A, LLLT was administered followed by the administration of a standard local anesthetic agent. Patients' perception of pain with use of LLLT was assessed based on a Visual Analogue Scale (VAS). In Condition B, LLLT was directed to the mucosa but not activated, followed by the administration of local anesthesia. VAS was used to assess the pain level without the use of LLLT.

Results

Comparison between Condition A and Condition B was done. A P value < 0.001 was considered significant, indicating a definite statistical difference between the two conditions.

Conclusion

In our study, we observed that LLLT reduced pain during injection of local anesthesia. Further multi-centric studies with a larger sample size and various modifications in the study design are required.

Reducing blood draw phobia in an adult with autism spectrum disorder using low-cost virtual reality exposure therapy

BACKGROUND

Needle phobias are common in children and adults worldwide. One effective intervention for this phobia is exposure therapy where a participant is gradually exposed to increasing levels of the fear-evoking stimulus while differential reinforcement is applied. This intervention, however, may be difficult to implement with some medical procedures as it may be difficult to obtain unfettered access to medical facilities and equipment for the purposes of exposure. Virtual reality may overcome these obstacles.

METHODS

In this investigation, the present authors developed a low-cost virtual reality-based exposure therapy which was used with an adult male with autism spectrum disorder and a history of extreme needle phobia. The effectiveness of this intervention was evaluated using a changing criterions design with generalization probes.

RESULTS

The intervention quickly increased the participant's compliance in the analogue training setting and the effects were generalized across settings and behaviours, and maintained over time.

CONCLUSIONS

The findings indicate combining virtual reality with exposure therapy may produce an effective intervention for medical phobias. The intervention package may remove barriers associate with traditional exposure therapy and was low-cost which may increase access to the intervention.

Humanization interventions in general pediatric wards: a systematic review

Humanization of care (HOC) interventions have rarely been evaluated and compared. We systematically reviewed the outcomes of published interventions aimed to improve the HOC for hospitalized children. PubMed and Scopus were used as data sources. Studies published between January 1, 2000, and February 28, 2018, were considered eligible if they reported analysis of results vs. either a control group or baseline, or if they measured patient/family/staff satisfaction. Neonatal age, emergency departments, and subspecialty settings were excluded. Data were extracted using a standardized data extraction form including study design, sample size, intervention, outcome/objective, and evaluation of results or pre- post-intervention satisfaction. Twenty-eight of the 12,012 retrieved articles met the inclusion criteria. Most studies were of moderate to low quality. Only six studies were of high quality. Areas of interest dealt with environment (n = 4), provider-patient relationship (n = 6), pet therapy (n = 5), technology (n = 5), family-centered rounds (n = 2), psychological support (n = 3), and staff training (n = 3). The overall trend of the results indicated that interventions were mostly effective and likely to have beneficial effects on several aspects of pediatric hospitalization.Conclusions: Pending further studies of better research quality, the findings of this review may have policy and practice implications for planning HOC interventions by pediatric healthcare professionals. What is Known: • In pediatrics, humanization of care (HOC) provides assistance focused not only on the child as a patient, but on the whole family. • HOC programs have been developed, but information on the overall outcome of local projects aiming to improve in a practical way the hospital taking charge of pediatric patients is still lacking. What is New: • Local HOC interventions are mostly effective and have beneficial effects on several aspects of hospitalization in general pediatrics wards. • The findings of this review may have practice implications for planning HOC interventions by pediatric healthcare professionals.

Special considerations for clinical trials in fibrodysplasia ossificans progressiva (FOP)

Clinical trials for orphan diseases are critical for developing effective therapies. One such condition, fibrodysplasia ossificans progressiva (FOP; MIM#135100), is characterized by progressive heterotopic ossification (HO) that leads to severe disability. Individuals with FOP are extremely sensitive to even minor traumatic events. There has been substantial recent interest in clinical trials for novel and urgently‐needed treatments for FOP. The International Clinical Council on FOP (ICC) was established in 2016 to provide consolidated and coordinated advice on the best practices for clinical care and clinical research for individuals who suffer from FOP. The Clinical Trials Committee of the ICC developed a focused list of key considerations that encompass the specific and unique needs of the FOP community – considerations that are endorsed by the entire ICC. These considerations complement established protocols for developing and executing robust clinical trials by providing a foundation for helping to ensure the safety of subjects with FOP in clinical research trials.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

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.

Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors

The purpose of this clinical update is to provide an overview of the fear of needles and needle phobia in children and adolescents including characteristics and diagnosis, prevalence and epidemiology, etiological factors, and treatment options. Needle-related fear and needle phobia present as significant needle-related distress and avoidance behavior. The etiology is biopsychosocial. These challenging conditions are more common in children and adolescents than in adults. The nurse–patient relationship enables the provision of suitable preparation before injection procedures. Nurses can use exposure-based interventions and incorporate coping strategies and teaching of parents and children. Nurses play a pivotal role in noticing the need for further treatment. Procedural needle-related distress is a complex phenomenon representing a continuum ranging from needle fear to more severe needle phobia. For patients with needle fear management and training methods used by nurses can possibly prevent a progression of the condition into needle phobia. In cases of needle phobia, a correct diagnosis made by a psychiatrist is necessary and enables referral to a psychotherapist with experience in treating children and adolescents with needle phobia.

Treating specific phobias in young people with autism and severe learning difficulties

Animal phobias in young people with autism spectrum disorders (ASD) and intellectual disability (ID) can provoke behaviours that put them at risk and impede access to the community. Previous studies suggest that cognitive behavioural therapy including systematic desensitization and modelling are effective for people with ID, including those with comorbid ASD. Methods of adapting such treatment to people with little spoken language are not well described, and ethical issues concerning both young people and animals during treatment have not been addressed. The aim of this study was to describe, using a case series of consecutive referrals: (1) adaptations to systematic desensitization when communication of the young person is impaired, and (2) the ethics of involving animals in therapeutic interventions. Treatment was planned based on the use of systematic desensitization with a hierarchy of feared situations using visual symbols and schedules to communicate with the participants. Five young people with ASD, severe ID and minimal language were successfully treated for dog phobia. Modifications to treatment included both the use of non-verbal means of communication including printed symbols and graded activities such as jigsaw puzzles and picture matching to present information to clients in a more finely graded format. The treatment of specific phobias is possible with the use of minimal language provided that a variety of individualized stimuli approximating to the feared objects are developed and the safety of all participants is respected. Further work is required to develop sufficiently flexible treatment protocols, which in turn would enable a randomized controlled trial.

Initial validation of a virtual blood draw exposure paradigm for fear of blood and needles

Fear of blood, injections, and needles commonly prevents or delays individuals' receipt of health care, such as vaccines or blood draws. Innovative methods are needed to overcome these fears and reduce anxiety related to activities of this nature. The present study describes initial testing of an arm illusion paradigm that may prove useful during early phases of graded exposure for people with blood and needle fear. Seventy-four undergraduate students aged 18-29 years were tested. In line with study aims, results indicated that the virtual blood draw paradigm promoted strong perceptions of arm ownership and elicited significant changes in physiological indices (blood pressure, heart rate, electrodermal activity, respiratory rate) in response to key procedure elements (e.g., needle insertion). Further, bivariate correlations indicated that individual differences in self-reported blood and needle fear collected prior to the illusion paradigm were significantly associated with presyncopal symptoms reported following the procedure. In regression analyses, self-reported measures of blood and needle fear explained unique variance in presyncopal symptoms even after controlling for general state anxiety. These findings provide initial support for the virtual blood draw paradigm as a promising tool to help provide graded exposure to medical procedures involving needles and blood draw.

Cognitive Behavioral Therapy for Anxiety and Fear in Pediatric Pain Contexts

Pain is a highly prevalent experience in pediatric medical populations, both in an acute form (e.g., iatrogenic pain from needle procedures) as well as in more chronic forms (e.g., as a result of arthritis, inflammatory bowel disease, or as a disease/disorder in and of itself). Guided by the biopsychosocial model, the overarching objective of this work is to examine cognitive behavioral treatment of anxiety in pain contexts. Specific aims are to (a) provide a brief overview of anxiety in youth with a high fear of needles and those experiencing chronic pain, (b) review the evidence base for cognitive behavioral therapy (CBT) for these populations, (c) outline considerations for implementing CBT-based approaches, and (d) provide two case examples which illustrate the application of CBT in these contexts. Brief concluding remarks include suggestions for future research such as improved screening and treatment of comorbid anxiety in the context of pain.

Methodology for Knowledge Synthesis of the Management of Vaccination Pain and Needle Fear

Supplemental Digital Content is available in the text.

Background:

A knowledge synthesis was undertaken to inform the development of a revised and expanded clinical practice guideline about managing vaccination pain in children to include the management of pain across the lifespan and the management of fear in individuals with high levels of needle fear. This manuscript describes the methodological details of the knowledge synthesis and presents the list of included clinical questions, critical and important outcomes, search strategy, and search strategy results.

Methods:

The Grading of Assessments, Recommendations, Development and Evaluation (GRADE) and Cochrane methodologies provided the general framework. The project team voted on clinical questions for inclusion and critically important and important outcomes. A broad search strategy was used to identify relevant randomized-controlled trials and quasi-randomized-controlled trials. Quality of research evidence was assessed using the Cochrane risk of bias tool and quality across studies was assessed using GRADE. Multiple measures of the same construct within studies (eg, observer-rated and parent-rated infant distress) were combined before pooling. The standardized mean difference and 95% confidence intervals (CI) or relative risk and 95% CI was used to express the effects of an intervention.

Results:

Altogether, 55 clinical questions were selected for inclusion in the knowledge synthesis; 49 pertained to pain management during vaccine injections and 6 pertained to fear management in individuals with high levels of needle fear. Pain, fear, and distress were typically prioritized as critically important outcomes across clinical questions. The search strategy identified 136 relevant studies.

Conclusions:

This manuscript describes the methodological details of a knowledge synthesis about pain management during vaccination and fear management in individuals with high levels of needle fear. Subsequent manuscripts in this series will present the results for the included questions.

Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.

Translation of the Medical Fear Survey to Serbian: psychometric properties

BACKGROUND

Medical Fear Survey (MFS) is an instrument designed for measuring fear of medical and related treatments.

OBJECTIVE

Aim of the present study was MFS translation into Serbian, measurement of its psychometric properties and MFS validation using other Blood-injury-injections and related stimuli instruments that have been translated from English into Serbian.

METHOD

After obtaining permission from the author of the original MFS, double forward translation from English to Serbian and backward translation to English were conducted in ten steps, according to International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. Reliability, factorial analysis and concurrent validation of Serbian version of MFS were conducted on a sample of 485 medical or pharmacy students at University of Kragujevac, Serbia.

RESULTS

Serbian version of MFS showed high internal consistency with a Cronbach's alpha 0.968 and good temporal stability after testing-and-retesting (Spearman's correlation coefficient 0.838, and intraclass correlation coefficient 0.877). Factorial analysis confirmed the same five factors demonstrated in the original English version: fear of mutilated bodies (10 items), fear of blood (11 items), fear of injections and blood draws (9 items), fear of sharp objects (10 items), and fear of medical examinations and physical symptoms (10 items). The total score of MFS correlated significantly with the total scores of Injection Phobia Scale-Anxiety (Spearman's correlation coefficient 0.391, p <0.001), Blood/Injection Fear Scale (Spearman's correlation coefficient 0.502, p <0.001) and Medical Avoidance Survey (Spearman's correlation coefficient 0.396, p <0.001).

CONCLUSIONS

Serbian version of the 50-item MFS showed similar psychometric properties as the original English version of this scale, with the same factorial structure. It could be used for measurement of fear of medical and related treatments in Serbian socio-cultural milieu, preferably self-administered. Hippokratia 2016, 20(1): 44-49.

Simple Psychological Interventions for Reducing Pain From Common Needle Procedures in Adults: Systematic Review of Randomized and Quasi-Randomized Controlled Trials

BACKGROUND

This systematic review evaluated the effectiveness of simple psychological interventions for managing pain and fear in adults undergoing vaccination or related common needle procedures (ie, venipuncture/venous cannulation).

DESIGN/METHODS

Databases were searched to identify relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear were prioritized as critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk (RR) with 95% confidence intervals (CI).

RESULTS

No studies involving vaccination met inclusion criteria; evidence was drawn from 8 studies of other common needle procedures (eg, venous cannulation, venipuncture) in adults. Two trials evaluating the impact of neutral signaling of the impending procedure (eg, "ready?") as compared with signaling of impending pain (eg, "sharp scratch") demonstrated lower pain when signaled about the procedure (n=199): SMD=-0.97 (95% CI, -1.26, -0.68), after removal of 1 trial where self-reported pain was significantly lower than the other 2 included trials. Two trials evaluated music distraction (n=156) and demonstrated no difference in pain: SMD=0.10 (95% CI, -0.48, 0.27), or fear: SMD=-0.25 (95% CI, -0.61, 0.10). Two trials evaluated visual distraction and demonstrated no difference in pain (n=177): SMD=-0.57 (95% CI, -1.82, 0.68), or fear (n=81): SMD=-0.05 (95% CI, -0.50, 0.40). Two trials evaluating breathing interventions found less pain in intervention groups (n=138): SMD=-0.82 (95% CI, -1.21, -0.43). The quality of evidence across all trials was very low.

CONCLUSIONS

There are no published studies of simple psychological interventions for vaccination pain in adults. There is some evidence of a benefit from other needle procedures for breathing strategies and neutral signaling of the start of the procedure. There is no evidence for use of music or visual distraction.