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2.  Children under 15 kg with food allergy may be at risk of having epinephrine auto-injectors administered into bone 
Background
The Epipen® Jr and Allerject® 0.15 mg are currently the most commonly prescribed epinephrine auto-injectors (EAIs) for the management of anaphylaxis in pediatric patients in North America and Canada. To ensure rapid absorption, it should be administered intramuscularly into the anterolateral aspect of the thigh. We examined whether the 12.7-mm needle length of the Epipen® Jr and Allerject® 0.15 mg is adequate for delivering epinephrine intramuscularly in pediatric patients who weighed <15 kg.
Methods
Consecutive pediatric patients with food allergy weighing <15 kg who required an EAI were included. Ultrasounds of the mid-anterolateral thigh were performed under minimal (min) and maximal (max) pressure. Skin-to-muscle depth (STMD) and skin-to-bone depth (STBD) measurements were completed. Baseline characteristics were compared between patients with a STBDmax <12.7 mm vs. ≥12.7 mm. Linear regression including variables such as age, sex, body mass index (BMI) and race was performed. The proportion of patients with a STBDmax <12.7 mm was compared in those weighing <10 kg vs. 10–14.9 kg.
Results
One hundred patients were included; 29 (29%) had STBDmax <12.7 mm. Height (p = 0.02) and weight (p = 0.0002) differed significantly between the two groups. Approximately 19% of those weighing 10–14.9 kg and 60% of those <10 kg had a STBDmax <12.7 mm. In the multivariable regression analysis, BMI was found to be a significant predictor of STBDmax.
Conclusions
A large proportion of children <15 kg prescribed an EAI is at risk of having the auto-injector administered into bone. Since alternative EAIs with shorter needle lengths are not currently available, EAIs should be prescribed with appropriate counselling in this population.
doi:10.1186/1710-1492-10-40
PMCID: PMC4126643  PMID: 25110478
Food allergy; Anaphylaxis; Skin-to-bone depth; Epinephrine; Auto-injector; Pediatric; Needle length
3.  Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy 
Background
Epinephrine auto-injectors are the standard first aid treatment for anaphylaxis. Intramuscular delivery into the anterolateral aspect of the thigh is recommended for optimal onset of action of epinephrine. The most frequently prescribed auto-injector in North America and Canada is the EpiPen®, which has a needle length of 15.2 mm. Currently, it is unknown whether this needle length is adequate for intramuscular delivery of epinephrine in adult patients at risk of anaphylaxis.
Methods
One hundred consecutive adult patients with confirmed food allergy requiring an epinephrine auto-injector were recruited. Skin to muscle depth (STMD) at the right mid-anterolateral thigh was measured using ultrasound under minimal (min) and maximum (max) pressure. The EpiPen® needle length was considered adequate if STMDmax was ≤15.2 mm. Baseline characteristics including age, gender, ethnicity, and body mass index (BMI) were compared in patients with STMDmax ≤15.2 mm vs. >15.2 mm.
Results
The EpiPen® needle length of 15.2 mm was inadequate for intramuscular delivery in 19 of the 100 enrolled patients (19%), all of whom were female; 28% of women had a STMDmax >15.2 mm. The mean STMDmax in the ≤15.2-mm and >15.2-mm groups were 9 ± 4 mm and 20 ± 4 mm, respectively (p = 0.0001). Linear regression analysis found BMI to be significantly associated with STMDmax after adjusting for age (p < 0.001).
Conclusions
The needle length of the epinephrine auto-injectors may not be adequate for intramuscular delivery of epinephrine in a large proportion of women with food allergy; this may impact morbidity and mortality from anaphylaxis in this patient population.
doi:10.1186/1710-1492-10-39
PMCID: PMC4112615  PMID: 25071856
Food allergy; Anaphylaxis; Skin-to-muscle depth; Epinephrine; Auto-injector; Needle length
4.  Patients on subcutaneous allergen immunotherapy are at risk of intramuscular injections 
Background
Allergen-specific subcutaneous immunotherapy is an effective treatment for certain allergic disorders. Ideally, it should be administered into the subcutaneous space in the mid-posterolateral upper arm. Injections are commonly given using a standard allergy syringe with a needle length of 13 mm. Therefore, there is a risk of intramuscular administration if patients have a skin-to-muscle depth <13 mm, which may increase the risk of anaphylaxis. The objective of this study was to determine whether the needle length of a standard allergy syringe is appropriate for patients receiving subcutaneous immunotherapy.
Methods
Ultrasounds of the left posterolateral arm were performed to measure skin-to-muscle depth in 200 adults receiving subcutaneous immunotherapy. The proportion of patients with a skin-to-muscle depth >13 mm vs. ≤13 mm was assessed and baseline characteristics of the two groups were compared. The proportion of patients with skin-to-muscle depths > 4 mm, 6 mm, 8 mm and 10 mm were also calculated. Multivariable logistic regression was performed to identify predictors of skin-to-muscle depth.
Results
Of the 200 patients included in the study, 80% had a skin-to-muscle depth ≤13 mm; the majority (91%) had a skin-to-muscle depth >4 mm. Body mass index was found to be a significant predictor of skin-to-muscle-depth.
Conclusions
Most patients receiving subcutaneous immunotherapy have a skin-to-muscle depth less than the needle length of a standard allergy syringe (13 mm). These patients are at risk of receiving injections intramuscularly, which may increase the risk of anaphylaxis. Using a syringe with a needle length of 4 mm given at a 45° angle to the skin may decrease this risk.
doi:10.1186/1710-1492-10-22
PMCID: PMC4017082  PMID: 24822074
Allergen-specific immunotherapy; Subcutaneous immunotherapy; Ultrasound; Skin-to-muscle depth; Needle length; Allergy syringe; Injections
7.  Intra-thoracic fat volume is associated with myocardial infarction in patients with metabolic syndrome 
Background
Visceral adiposity is increased in those with Metabolic Syndrome (MetS) and atherosclerotic disease burden. In this study we evaluate for associations between intra-thoracic fat volume (ITFV) and myocardial infarction (MI) in patients with MetS.
Methods
Ninety-four patients with MetS, MI or both were identified from a cardiovascular CMR clinical registry. MetS was defined in accordance to published guidelines; where-as MI was defined as the presence of subendocardial-based injury on late gadolinium enhancement imaging in a coronary vascular distribution. A healthy control group was also obtained from the same registry. Patients were selected into the following groups: MetS+/MI- (N = 32), MetS-/MI + (N = 30), MetS+/MI + (N = 32), MetS-/MI- (N = 16). ITFV quantification was performed using signal threshold analysis of sequential sagittal CMR datasets (HASTE) and indexed to body mass index.
Results
The mean age of the population was 59.8 ± 12.5 years. MetS+ patients (N=64) demonstrated a significantly higher indexed ITFV compared to MetS- patients (p = 0.05). Patients in respective MetS-/MI-, MetS+/MI-, MetS-/MI+, and MetS+/MI + study groups demonstrated a progressive elevation in the indexed ITFV (22.3 ± 10.6, 28.6 ± 12.6, 30.6 ± 12.3, and 35.2 ± 11.4 ml/kg/m2, (p = 0.002)). Among MetS+ patients those with MI showed a significantly higher indexed ITFV compared to those without MI (p = 0.02).
Conclusions
ITFV is elevated in patients with MetS and incrementally elevated among those with evidence of prior ischemic myocardial injury. Accordingly, the quantification of ITFV may be a valuable marker of myocardial infarction risk among patients with MetS and warrants further investigation.
doi:10.1186/1532-429X-15-77
PMCID: PMC3847137  PMID: 24020829
Fat distribution; Adiposity; Metabolic syndrome; Myocardial infarction

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