An angled insertion technique using 6-mm needles markedly reduces the risk of intramuscular injections in children and adolescents.

AIMS: The aims of this study were (i) to establish which children with Type 1 diabetes are at risk of intramuscular or intradermal insulin injections and (ii) to determine a needle length and technique that reliably administers insulin into subcutaneous fat. METHODS: Seventy-two healthy diabetic children (age 6.3-14.3 years, body mass index standard deviation score 1.0 +/- 1.4) were recruited for study 1 and 37 of this cohort participated in study 2. In study 1, 200 microl air was injected into the abdomen and anterior thigh by a pinched skin-fold technique using either a perpendicular insertion of NovoFine(R) 31G 6-mm or an angled insertion of NovoFine(R) 30G 8-mm needles. In study 2, subjects received injections into abdomen and anterior thigh via angled 6-mm needles with either an unpinched or pinched technique. The site of air injection was visualized by ultrasound scan and measurements taken of subcutaneous fat thickness. RESULTS: In study 1, intramuscular injections were detected in 32% of subjects, and in a further 22% air was visualized at the muscle fascia. In study 2, intramuscular injections occurred in 3% of subjects and a further 11% had muscle fascia air detected. No intramuscular injections occurred in subjects injecting with a 6-mm needle and an angled pinched skin-fold technique. Pinching abdomen and thigh skin folds increased the subcutaneous fat thickness by 192 +/- 16% and 22 +/- 6%, respectively. In very lean subjects, pinching thighs actually reduced subcutaneous fat thickness. CONCLUSIONS: While intramuscular injections were observed frequently using standard injection protocols, an angled 6-mm needle technique reliably injects into the subcutaneous fat.

Mal (MyD88-adapter-like) is required for Toll-like receptor-4 signal transduction.

The recognition of microbial pathogens by the innate immune system involves Toll-like receptors (TLRs), which recognize pathogen-associated molecular patterns. Different TLRs recognize different pathogen-associated molecular patterns, with TLR-4 mediating the response to lipopolysaccharide from Gram-negative bacteria. All TLRs have a Toll/IL-1 receptor (TIR) domain, which is responsible for signal transduction. MyD88 is one such protein that contains a TIR domain. It acts as an adapter, being involved in TLR-2, TLR-4 and TLR-9 signalling; however, our understanding of how TLR-4 signals is incomplete. Here we describe a protein, Mal (MyD88-adapter-like), which joins MyD88 as a cytoplasmic TIR-domain-containing protein in the human genome. Mal activates NF-kappaB, Jun amino-terminal kinase and extracellular signal-regulated kinase-1 and -2. Mal can form homodimers and can also form heterodimers with MyD88. Activation of NF-kappaB by Mal requires IRAK-2, but not IRAK, whereas MyD88 requires both IRAKs. Mal associates with IRAK-2 by means of its TIR domain. A dominant negative form of Mal inhibits NF-kappaB, which is activated by TLR-4 or lipopolysaccharide, but it does not inhibit NF-kappaB activation by IL-1RI or IL-18R. Mal associates with TLR-4. Mal is therefore an adapter in TLR-4 signal transduction.

Rac1 regulates interleukin 1-induced nuclear factor kappaB activation in an inhibitory protein kappaBalpha-independent manner by enhancing the ability of the p65 subunit to transactivate gene expression.

We have examined the involvement of Rac1 in nuclear factor kappaB (NFkappaB) activation by interleukin 1 (IL1). IL1 induced a rapid and sustained activation of Rac1 in the thymoma cell line EL4.NOB-1. Transient transfection with dominant negative RacN17 inhibited IL1-induced kappaB-dependent reporter gene expression but not IkappaBalpha degradation, whereas constitutively active RacV12 potentiated kappaB-dependent reporter gene expression in response to IL1 but had no effects on its own. Using porcine aortic endothelial cells stably transfected with RacV12 or RacN17 under the control of an inducible promoter, we confirmed that RacV12 did not affect IkappaBalpha degradation, nor did RacN17 inhibit the IL1-induced response. RacV12 was also unable to induce nuclear translocation of NFkappaB. These effects suggested a role for Rac1 in p65-mediated transactivation of NFkappaB, independent of IkappaBalpha regulation. In support of this we found that IL1 activated a pathway leading to increased p65 transactivation activity and that RacV12 alone could drive this response in both cell systems. Additionally, RacN17 inhibited IL1-driven p65-mediated transactivation. From data using specific inhibitors of p38 and p42/p44 kinases we propose that both p38 and p42/p44 lie downstream of Rac1 on the IL1 pathway leading to enhanced transactivation by p65.