The Effect of a Combination of Vibration and External Cold on Pain Caused during Vaccine Injection in Infants: A Randomized Clinical Trial.

Aim: This study was conducted to determine the effect of combining vibration and external cold on pain caused by vaccine injection among six-month-old infants. Design: Randomized controlled trial. Methods: In this clinical trial, 80 eligible infants were selected from the infants referred to a health center as per the inclusion criteria. The infants were assigned to either a control group or an intervention group by block randomization. In the intervention group, a vibrating and cold device was placed above the injection site from one minute before to 15 seconds after the pentavalent vaccine injection. In the control group, no intervention was performed, and they were vaccinated according to the routine procedure. The pain status in the two groups was measured using the Modified Behavioral Pain Scale (MBPS) 15 seconds after the injection, and the crying duration was assessed from the injection of the vaccine till the end of it. Data were analyzed in SPSS 23 software using Mann-Whitney, t, Spearman, and chi-square tests. The level of significance was set to p < 0.05. Results: Most participants in the control (55%) and intervention (55%) groups were girls. Statistical data analysis of 80 infants showed that the mean pain intensity (p = 0.032) and duration of crying (p = 0.0001) in the intervention group (6.1 ± 1.8, 32.47 ± 16.78) were lower than those of the control group (7.2 ± 0.1, 51.02 ± 25.9), respectively. Conclusion: Because the intensity of pain, especially the duration of crying, was lower in the intervention group than in the control group, we may suggest that nurses use simple pain relief solutions in vaccination centers, such as a combination of vibration and cold. This trial is registered with IRCT201207157130N2.

Injections of the Hip and Knee.

Hip and knee injections are useful diagnostic and therapeutic tools for family physicians. This article reviews anatomic landmark-guided and ultrasound-guided injections and aspiration techniques for greater trochanteric pain syndrome, the hip joint, the knee joint, the pes anserine bursa, and the iliotibial band. Indications for injections include acute and chronic inflammatory conditions, such as rheumatoid arthritis; osteoarthritis; overuse; and traumas. Joint aspirations may be performed to aid in the diagnosis of unexplained effusions and to relieve pain. Technique, injectant, and follow-up timing depend on the physician's comfort, experience, and preference. Infections of the skin or soft tissue are the primary contraindications to injections. The most common complications are local inflammatory reactions to the injectant. These reactions usually cause soreness for 24 to 48 hours, then spontaneously resolve. Follow-up after injections is usually scheduled within two to six weeks.

Preclinical Animal Study and Pilot Clinical Trial of Using Enriched Peripheral Blood-Derived Mononuclear Cells for Intervertebral Disc Degeneration.

Low back pain (LBP) is a leading cause of long-term disability globally. Intervertebral disk degeneration (IVDD) is mainly responsible for discogenic pain in LBP-affected young patients. There is no effective therapy to reverse disease severity and IVDD progression. This study investigates the effect of human peripheral blood-derived mononuclear cells (PBMCs) on pain relief and life quality improvement in IVDD patients. The enriched monocytes of the PBMCs could differentiate into CD14 and CD206 double-positive M2 macrophages in vitro. Preclinical evidence in rats showed that the transplanted PBMCs exhibited anti-inflammatory and moderate tissue-repair effects on controlling IVDD progress in the rat model. The PBMCs significantly steered the aggrecan and type II collagen expressions and attenuated the pro-inflammatory cytokines in the affected disk. Based on the animal results, 36 patients with chronic low back pain (CLBP) were included in clinical trials. The control group was conservative care only, and the experimental group was platelet-rich plasma (PRP) and PBMCs intradiscal injections. We first confirmed the single lumbar disk causing the discogenic pain by provocative discography or magnetic resonance imaging (MRI). Discogenic LBP participants received one intradiscal injection of autologous PBMCs and followed for 6 months. Our clinical trial showed that patients' LBP and disability were significantly ameliorated after the PBMCs transplantation rather than PRP. These preclinical and pilot clinical studies indicate that intradiscal injection of the enriched PBMCs might be a feasible and potential cell therapy to control pain and disability in IVDD patients.

Essential Palatal Myoclonus and Clicking Tinnitus in a Nine-Year-Old Boy-A Case Report.

The work describes a case of palatal myoclonus with distressing tinnitus in a 9-year-old boy and its successful treatment with injections of botulinum toxin. This case report discusses common questions about myoclonic-induced clicking tinnitus and provides answers. Laryngoscope, 134:397-399, 2024.

[Effectiveness and interest of retrobulbar hyaluronidase injections in the treatment of blindness complicating facial hyaluronic acid injections: A literature review]. / Efficacité et intérêt des injections rétrobulbaires de hyaluronidase dans le traitement des cécités compliquant une injection faciale d'acide hyaluronique : revue de la littérature.

INTRODUCTION: Hyaluronic acid injections are becoming increasingly common among both the general public and the medical community, but they are not without risks. The occurrence of blindness, although rare, is a tragic event for both the patient and the practitioner. One of the treatments proposed in the literature is to inject hyaluronidase as close as possible to the site of ischemia, retrobulbarly. The aim of our study is to evaluate the effectiveness and potential benefits of retrobulbar hyaluronidase injections. MATERIALS AND METHODS: A literature review was conducted using the PubMed database. Only articles addressing retrobulbar hyaluronidase injections for the treatment of blindness following hyaluronic acid injections were included. RESULTS: We identified 12 case reports or series, comprising a total of 16 patients. Among these 16 patients, 3 regained their vision. Hyaluronidase was injected between 20minutes and 7days after the onset of the complication, with injected doses ranging from 3×150IU to 3×1500IU. DISCUSSION: Literature reveals only 3 cases of successful treatment out of the 16 reported injections. The time interval before retrobulbar injection, as well as the dose and the experience of the injecting practitioner, may influence the success rate of this treatment. Other treatments, such as intravascular hyaluronidase injections, remain to be explored.

Actitudes asociadas a las prácticas de inyección de riesgo en personas que se inyectan drogas en Palma de Mallorca / Attitudes associated with risky injection practices in people who inject drugs in Palma de Mallorca

El objetivo de este estudio fue explorar las actitudes de las personas que se inyectan drogas (PID) y realizan prácticas de inyección de riesgo, identificando los factores subyacentes a su discurso que sustentan esas actitudes. Se planteó una investigación cualitativa con un diseño de grupos de discusión con PID (n = 34) y entrevistas a expertos(as) (n = 3). Los grupos y entrevistas fueron grabados, transcritos y analizados bajo el enfoque de la teoría fundamentada y el método del análisis temático. Se identificaron 17 categorías de riesgo, agrupadas en seis dimensiones: Consumo de drogas, Conocimiento, Confianza en otras personas, Acceso a jeringuillas nuevas, Situación personal y Azar. Estas dimensiones modularían la magnitud de las actitudes hacia las distintas prácticas de inyección de riesgo o actuarían como barreras que socavan la intención de las PID de inyectarse de manera segura. El discurso analizado sugiere que muchas PID han desarrollado actitudes poco negativas, neutras o incluso positivas hacia algunas prácticas de inyección de riesgo, principalmente hacia su realización en situaciones determinadas y aun conociendo las consecuencias negativas que estas entrañan. Proponer una descripción diferenciada de las actitudes asociadas a las prácticas de inyección de riesgo no sólo contribuye a profundizar en su explicación, sino que permitirá una mayor adecuación de los programas preventivos a las necesidades específicas de las PID. (AU)

The goal of this study was to explore the attitudes of people who inject drugs (PWID) and carry out risky practices, identifying underlying factors in their speech that sustain those attitudes. We proposed a qualitative research design with PWID focus groups (n = 34) and interviews with experts (n = 3). The interviews were recorded, transcribed, and analyzed following the principles of grounded theory and thematic analysis methodology. A total of 17 risk categories were identified and grouped into six dimensions: Drug Consumption, Knowledge, Trust In Other People, Access To Unused Syringues, Personal Situation, and Random. These dimensions would modulate the magnitude of the attitudes towards the different risky injection practices or act as barriers that limit the intention of PWID to inject themselves in a safe way. The analysis of the narratives suggests that many PWID have developed slightly negative, neutral, or even positive attitudes towards some risky injection practices, mainly towards carrying them out in certain situations and even when knowing of their negative consequences. Characterizing the attitudes associated with risky injection practices not only contributes to understanding them more thoroughly but will also allow preventive programs to be better suited to the specific needs of PWID. (AU)

Botulinum toxin A dissolving microneedles for hyperhidrosis treatment: design, formulation and in vivo evaluation.

Multiple periodic injections of botulinum toxin A (BTX-A) are the standard treatment of hyperhidrosis which causes excessive sweating. However, BTX-A injections can create problems, including incorrect and painful injections, the risk of drug entry into the bloodstream, the need for medical expertise, and waste disposal problems. New drug delivery systems can substantially reduce these problems. Transdermal delivery is an effective alternative to conventional BTX-A injections. However, BTX-A's large molecular size and susceptibility to degradation complicate transdermal delivery. Dissolving microneedle patches (DMNPs) encapsulated with BTX-A (BTX-A/DMNPs) are a promising solution that can penetrate the dermis painlessly and provide localized translocation of BTX-A. In this study, using high-precision 3D laser lithography and subsequent molding, DMNPs were prepared based on a combination of biocompatible polyvinylpyrrolidone and hyaluronic acid polymers to deliver BTX-A with ultra-sharp needle tips of 1.5 ± 0.5 µm. Mechanical, morphological and histological assessments of the prepared DMNPs were performed to optimize their physicochemical properties. Furthermore, the BTX-A release and diffusion kinetics across the skin layers were investigated. A COMSOL simulation was conducted to study the diffusion process. The primary stability analysis reported significant stability for three months. Finally, the functionality of the BTX-A/DMNPs for the suppression of sweat glands was confirmed on the hyperhidrosis mouse footpad, which drastically reduced sweat gland activity. The results demonstrate that these engineered DMNPs can be an effective, painless, inexpensive alternative to hypodermic injections when treating hyperhidrosis.

Profiles and Outcomes of Skin Injuries Caused by Injectable Drug Extravasation: An Analysis of the Japanese Adverse Drug Event Report Database.

Extravasation occurs when injectable drugs leak out of the blood vessels, damaging the surrounding tissues and causing a variety of skin injuries. This study aimed to comprehensively analyze extravasation risk, skin injury profiles, and outcomes for suspect drugs from the Japanese Adverse Drug Event Report (JADER) database. Adverse events were defined according to the Medical Dictionary for Regulatory Activities/Japanese version; the term extravasation (Standardized MedDRA Query Code: 20000136) was used in this analysis. The names of adverse events were entered as unified preferred terms and redefined to evaluate skin injury profiles. In addition, skin injury outcomes were divided into 2 broad categories: "improvement" and "no improvement." Reporting odds ratios were used to detect signals for adverse events. A total of 656 cases of extravasation-related adverse events were reported between April 2004 and January 2022. Signals for extravasation-related adverse events were detected from 11 drugs. Then, their respective skin injury profiles and outcomes were determined. These results suggest a relationship between adverse events associated with extravasation and 11 drugs and identify the characteristics of each skin injury and their outcomes. These findings will contribute to improving the quality of infusion management in clinical practice.

Injection of sodium hypochlorite into soft tissues of the oral cavity: A literature review with clinical preventive recommendations.

Injection of sodium hypochlorite (NaOCl) solution instead of local anaesthetic (LA) solution is an iatrogenic error with serious consequences including medico-legal implications. Such cases have been reported despite recommended precautionary measures. The purpose of this article is to review the literature on such cases and present clinical preventive recommendations. Electronic search was conducted in PubMed/Medline, Google Scholar, Cochrane, Scopus, Lilacs, ScienceDirect, and Crossref databases for articles reporting accidental or mistaken or inadvertent injection of NaOCl instead of LA during dental or endodontic treatment. Articles reporting NaOCl accident due to extrusion or injection of NaOCl beyond root confines were excluded. A total of 11 articles were found and reviewed. Data pertaining to the patient, injected NaOCl, cause, clinical manifestations, management, hospitalization, healing and recovery, and long-term or residual effects were extracted, compiled, and analysed for interpretation and discussion. Injection of NaOCl instead of LA into the soft tissues leads to varying clinical manifestations with unpredictable extent, outcome, and recovery period. The onus lies with the clinician to prevent it. Therefore, a clinician must take all the precautionary measures and confirm the identity of LA and NaOCl solutions before delivering them. The presented clinical recommendations assist clinicians to prevent it, including its potential medico-legal consequences. However, in case of such an unfortunate event, it is crucial to immediately identify and quickly manage it to limit the tissue damage or complications.

The Use of Botulinum Toxin in Raynaud Phenomenon: A Comprehensive Literature Review.

BACKGROUND: Raynaud phenomenon (RP) is a vasospastic condition of the digits that can be primary or secondary to systemic disease. Symptoms are triggered by cold or stress and can cause pain and skin color changes. The chronic ischemia may lead to necrosis, ulceration, and amputation. There are no Food and Drug Administration-approved treatments and cases refractory to pharmacologic and surgical treatments are difficult to control. Local botulinum toxin injections have been increasingly used in the treatment of Raynaud disease and have shown promising results. AIM OF THE STUDY: To examine the outcomes, techniques, and complications of botulinum toxin use for the treatment of Raynaud disease. METHODS: The PubMed database was queried using "botulinum toxin" AND "Raynaud phenomenon" as title key words. Preferred reporting items for systematic reviews and meta-analysis criteria were used. Additional articles were selected while reviewing the references of the articles from PubMed. No time restrictions were followed. Articles of all languages were included. Articles were analyzed for study type, demographics, diagnosis/inclusion criteria, treatment methods, outcome measures, length of follow-up, results, and complications. A positive outcome was defined as subjective improvement in symptoms and/or improvement in the outcome measures. A poor outcome was defined as harm done to the patient by the injection that would not have occurred otherwise. RESULTS: Forty-two clinical studies describing the use of botulinum toxin for Raynaud's phenomenon were found. A total of 425 patients with primary or secondary Raynaud's were treated, with ages ranging from 14 to 91 years. There were 342 women and 81 men, with a female-to-male ratio of 38:9. Outcomes were positive in 96.2% of patients. There were 14.2% of the studies that reported 3.5% of all patients showing no subjective improvement. A single study reported a poor outcome for 1 patient. There were 40.5% of the studies that reported complications, affecting 20.2% of all patients. The most frequently reported complication was transient hand weakness, affecting 44.2% of patients with complications and 8.9% of total patients. Weakness resolved in hours to months after injection. Pain at the injection site lasting minutes to days was reported in 40.7% of patients with complications, and 8.2% of total patients. CONCLUSIONS: Botulinum toxin treatment for RP is effective. Complications are minor and self-limiting.

Development and validation of a distress measurement for insulin injections among patients with diabetes.

Insulin injections are stressful but necessary for people with diabetes. This study aimed to develop and validate the Distress of Self-Injection (DSI) scale for patients with diabetes aged ≥ 10 years. We created a questionnaire to evaluate DSI after examining each item following a literature review. The DSI scale with 20 questions in three domains (physical [4], psychosocial [7], and process [9]) was developed and tested at the Samsung Medical Center in Seoul, Korea, from April to September 2021. To verify structural validity, exploratory and confirmatory factor analyses (CFA) were conducted. Internal consistency was also calculated. To assess construct and criterion validity, the correlation between the DSI scale and Korean version of the Problem Areas in Diabetes (PAID-K) scale was obtained. Cronbach's alpha varied from 0.69 to 0.87, and the DSI score was 0.90, demonstrating acceptable internal consistency. CFA fit indices (CFI = 0.980; RMSEA = 0.033) were favorable. DSI and pertinent PAID-K domains correlated strongly. For measuring self-injection distress, the DSI score had good accuracy. For patients with diabetes aged ≥ 10 years who self-inject insulin, the DSI was a viable and accurate method for quantifying discomfort associated with insulin injection. Health practitioners should use the DSI to communicate with patients about their suffering.

Remodelación total de glúteos en pacientes con inyección masiva de sustancias desconocidas / Total buttocks remodeling in patients with massive injection of unknown substances

Introducción y objetivo: Presentamos 2 casos clínicos de extirpación de gran cantidad de tejido afectado en pacientes con inyección masiva de materiales extraños en glúteos y el procedimiento reconstructivo empleado.Material y método: Describimos el procedimiento quirúrgico seguido tras la extirpación del material de infiltración, mediante disección de un colgajo dermograso de amplia base lateral que permite su avance en dirección medial para proveer tejido de la región superior del muslo lateral y conformar el nuevo glúteo. Resultados: El contorno final de los glúteos y la ubicación de las cicatrices obtuvo un alto grado de satisfacción en ambas pacientes. El postoperatorio fue largo y algo tórpido por retardo de la cicatrización. Uno de los casos requirió revisión. Conclusiones: Consideramos que los resultados obtenidos pueden ser una alternativa interesante para el tratamiento de esta patología, muy frecuente en la actualidad y de difícil resolución. (AU)

Background and objective: We present 2 clinical cases of surgical removal of foreign materials from the buttocks and the following reconstructive procedures in patients with massive injections of foreign materials. Methods: We describe the reconstructive procedure after the removal of the foreign material, with a dermal fat flap with a wide lateral base that allows to move the flap towards the center of the buttocks and provide tissue in the upper region of the lateral thigh, effectively reshaping the new gluteus. Results: The final contour of the buttocks and the placement of the scars were accepted with great satisfaction by both patients. The postoperative was long and slow due to prolonged scarring. One case required revision. Conclusions: We consider that the obtained results are encouraging and the method could make for an interesting alternative to treat this pathology, which is frequent and of difficult solution. (AU)

Tratamiento de las secuelas por inyección de metacrilato/biopolímero / Treatment of sequelae due to injection of mathacrylate/biopolymers

Presentamos una serie de casos en el que otros profesionales usaron biopolímeros para relleno y volumen en diferentes regiones del organismo, siendo la más frecuente la región glútea. El 60 % de las pacientes fueron de sexo femenino y el 40%, masculino. El 62% presentaba síntomas que excedían los síntomas locales; completando los estudios con laboratorio y/o imágenes, diagnosticamos síndrome de ASIA (autoimmune syndrome induced by adjuvants). El requerimiento original de los pacientes siempre fue mixto, algunos consultaron por la incomodidad de tener una región indurada y pétrea, sin movilidad y el resto por síntomas provenientes del producto inyectado. Los del primer grupo siempre referían síntomas generales. Se presenta una técnica novedosa y propia en la forma de encarar el tratamiento, que siempre es quirúrgico

We present a series of cases in which other professionals used biopolymers for filling and volume in different regions of the body, the most frequent the gluteal region. 60% of the patients were female and 40%, male. 62% had symptoms that exceeded local symptoms; completing the studies with laboratory and/or images, we diagnose ASIA (autoimmune syndrome induced by adjuvants) syndrome. The original requirement of the patients was always mixed, some consulted due to the discomfort of having an indurated and stony region, without mobility and the rest due to symptoms coming from the injected product. Those in the first group always reported general symptoms. A novel and proprietary technique is presented in the way of approaching the treatment, which is always surgical.

Central retinal artery occlusion following facial injection of hyaluronic acid.

A 57-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the right eye (RE). Best-corrected visual acuity in the RE was counting fingers to. A relative afferent pupillary defect was observed in the RE. Ocular fundus examination of RE was suggestive of central retinal artery occlusion. Systemic evaluation was normal. The most interesting fact in this case is that a hemorrhagic edema in the right glabellar region was the basis for the diagnostic suspicion. The patient recognized the loss of vision 24 h after hyaluronic acid injection as a facial rejuvenation treatment.

Four-Point Injection Technique of Polyacrylate/Polyalcohol Copolymer in Vesicoureteral Reflux After KidneyTransplant.

OBJECTIVES: Vesicoureteral reflux after kidney transplant is mostly asymptomatic, but recurrent urinary tract infections can cause graft rejection. Although the gold standard treatment is open surgical repair, we believe that endoscopic treatment can be further improved. Here, we investigated the long-term outcomes of 4-point endoscopic injection of polyacrylate/polyalcohol copolymer in patients with vesicoureteral reflux after kidney transplant. MATERIALS AND METHODS: Patients who had undergone 4-point endoscopic injectionofpolyacrylate/polyalcohol copolymer for symptomatic vesicoureteral reflux after kidney transplant and were followed for atleast 3 years were included. Patients with dysfunctional and/or obstructive voiding patterns, unsuccessful primary endoscopic treatment, concomitant injection of native kidney reflux, and incomplete follow-up were excluded. We evaluated patient characteristics, perioperative data, and clinical and radiological outcomes. Urine culture, serum creatinine, and renal ultrasonography were assessed every 3 months. Voiding cystourethrography was performed at month 3 and when recurrence was suspected. Clinical success was defined as absence of febrile urinary tract infection during follow-up, and radiological success was defined as absence of vesicoureteral reflux in the voiding cystourethrography. RESULTS: Of 21 study patients, 14 (66.6%) were female and 7 (33.3%) were male patients. Average age was 37.1 years (range, 12-62 years). According to preoperative voiding cystourethrography, 3 patients (14.2%) had grade II, 13 patients (61.9%) had grade III, and 5 patients (23.8%) had grade IV vesicoureteral reflux. Eighteen patients (85.7%) had clinical success with the first injection, and 20 patients (95.2%) had success with the second injection. Eleven patients (52.3%) demonstrated radiological success. The reflux degree of all patients, except 2, had partially or completely regressed. Ureteral balloon dilatation and double J stent implantation was performed in 1 patient (4.7%) due to ureteral obstruction. CONCLUSIONS: The 4-point injection of polyacrylate/- polyalcohol copolymer provided long-term permanent success for symptomatic vesicoureteral reflux after kidney transplant.

[What's new in the management of systemic sclerosis]. / Nouveautés dans la prise en charge de la sclérodermie systémique.

This review of the literature highlights the results of the recent randomized controlled trials about the management of systemic sclerosis (SSc) and its complications. The latest randomized studies have failed to demonstrate the utility against placebo of the injections of botulinum toxin A to achieve a better control of Raynaud's phenomenon and the efficacy of the adipose-derived cell transplantation for the treatment of hand dysfunction. Rituximab allows a significant improvement of cutaneous induration. The injections of mesenchymal stromal cells are well tolerated and should encourage future randomized trials to evaluate their efficacy. Finally, nintedanib and tocilizumab allow a reduction in the rate of decline of lung function, as well as a possible stabilization with tocilizumab.

Cet article expose les résultats des essais randomisés et contrôlés récents concernant la prise en charge de la sclérodermie systémique (SSc) et ses complications. Les études discutent l'utilité des injections de la toxine botulinique pour le contrôle du phénomène de Raynaud, et des injections de cellules dérivées du tissu adipeux pour améliorer la fonctionnalité de la main. Le rituximab permet une amélioration significative de l'induration cutanée, et les injections de cellules stromales mésenchymateuses, en plus d'être bien tolérées, ouvrent la voie à d'éventuels essais randomisés en vue d'évaluer leur efficacité. Finalement, le nintédanib et le tocilizumab permettent une réduction du taux de déclin de la fonction pulmonaire, jusqu'à une éventuelle stabilisation de cette dernière observée avec le tocilizumab.

High-pressure injection hand injury: What lies beneath?

ABSTRACT: High-pressure injection injuries are true emergencies that require prompt treatment to avoid devastating complications. This article describes the presentation and management of these injuries and provides clear and concise recommendations for intervention by the ED clinician.

[Insulin-derived amyloidosis (insulin ball) and skin-related complications of insulin therapy].

Skin-related complications of insulin therapy have long been a problem as a factor interfering with insulin therapy. Among the traditional skin-related complications, lipoatrophy and insulin allergy have decreased markedly with the development of insulin preparations, but lipohypertrophy is still common in insulin-treated patients. Recently, there have been more reports of a skin-related complication called insulin-derived amyloidosis or insulin ball. Insulin-derived amyloidosis is a condition in which injected insulin becomes amyloid protein and is deposited at the injection site. Insulin-derived amyloidosis causes poor glycemic control and increased insulin dose requirements, which are caused by decreased insulin absorption. Lipohypertrophy also decreases insulin absorption, but insulin-derived amyloidosis causes a more significant decrease in insulin absorption and has a greater clinical impact. Therefore, it is important to make a differential diagnosis between insulin-derived amyloidosis and lipohypertrophy, but sometimes it is difficult to distinguish the two and imaging studies are required. The diagnosis of insulin-derived amyloidosis is often difficult in the general practice, and its pathogenesis and prevalence have not been fully clarified. Recently, it has been reported that insulin-derived amyloidosis can be toxic, suggesting an association with minocycline use. The treatment of insulin-derived amyloidosis and lipohypertrophy is to avoid the site of amyloidosis or lipohypertrophy and inject insulin, but the dose of insulin injection should be reduced. Prevention of both insulin-derived amyloidosis and lipohypertrophy is important, and for this purpose, observations of the insulin injection site and instruction on appropriate insulin injection techniques are necessary, and multidisciplinary cooperation is extremely important.

[Introduction of a joint academic project between the Japan Academy of Nursing Science and the Japanese Pharmacological Society: a scoping review on assessment and preventive care of insulin balls].

Japanese Academy of Nursing Science (JANS) and the Japanese Pharmacological Society (JPS) have been conducting human interaction at each other's scientific meeting symposia in a home-and-away fashion since 2018. JANS and JPS have been working on a joint scientific project, "Scoping Review: Insulin Balls" since 2021. At the 95th Annual Meeting of the JPS held in 2022, we reported from a nursing perspective on the theme of "Assessment and preventive care of insulin balls from a scoping review". Subcutaneous injection into insulin balls has been reported to cause poor blood glucose control. Therefore, it is important to prevent insulin balls. In this study, we had the research questions, "What methods are available for assessment of the insulin injection site?" and "What is the care to prevent induration and how effective is it?" and conducted a scoping review. Regarding methods of injection site assessment, most of the literature identified the injection site by palpation, visual examination, and ultrasonography. About the preventive care, there were some reports of insulin balls occurring because patients have been injecting insulin at the same site, even though healthcare professionals instructed them to avoid the same site. Some of the literature had specific teaching methods such as hand site rotation and calendar injection method, and they were reported effective. In the future, we plan to proceed with the review including care after the development of insulin balls.

Death from Pulmonary Embolism Caused by Vaginal Injection of Hyaluronic Acid: a Case Report and a Literature Review.

A 40-year-old woman underwent vaginoplasty with intramural injection of fillers from an illegal medical practitioner. Approximately 2 h after the injection, she developed lower abdominal pain. The patient was taken to the hospital approximately 5 h later due to worsening pain. When the patient was admitted for physical examination, she suddenly experienced cardiac and respiratory arrest. She was resuscitated but remained in a coma. Unfortunately, the patient died approximately 12 h after being admitted to the hospital. The forensic autopsy revealed extensive amorphous basophilic emboli in the small interstitial vascular lumen of both lungs, and a large amount of the same type of substances were also found in the vaginal wall. Hyaluronidase digestion and Alcian blue staining confirmed that most components of the injection were hyaluronic acid (HA). HA is widely used as a cosmetic filler in the field of plastic surgery and is generally considered to have few adverse effects. This paper reports the first anatomical case of fatal pulmonary embolism caused by vaginal injection of HA. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .