Estimated IM injection risk in adults, by body site*.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"5978",leadTitle:null,fullTitle:"New Perspectives in Forage Crops",title:"New Perspectives in Forage Crops",subtitle:null,reviewType:"peer-reviewed",abstract:'In livestock management, the production of forage plants is undoubtedly the most efficient way to produce products of animal origin with quality and economic viability. We hope that the readers of the book "New Perspectives in Forage Crops" will have a good reading and appreciate the information provided on forage production, since the book draws on the expertise of different specialists of the area, who discuss the following aspects: fertilization, semiarid region production, forage species selection, nitrogen fixation, grasses, legumes, cacti, drought, etc. The authors of the book are of different nationalities and provide important information and diverse perspectives on the subject of forage farming.',isbn:"978-953-51-3721-4",printIsbn:"978-953-51-3806-8",pdfIsbn:"978-953-51-4012-2",doi:"10.5772/66549",price:119,priceEur:129,priceUsd:155,slug:"new-perspectives-in-forage-crops",numberOfPages:212,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"129c29bcddd8225ed58e908138b2cda5",bookSignature:"Ricardo Loiola Edvan and Leilson Rocha Bezerra",publishedDate:"January 17th 2018",coverURL:"https://cdn.intechopen.com/books/images_new/5978.jpg",numberOfDownloads:16315,numberOfWosCitations:22,numberOfCrossrefCitations:18,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:34,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:74,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"December 12th 2016",dateEndSecondStepPublish:"December 19th 2016",dateEndThirdStepPublish:"September 18th 2017",dateEndFourthStepPublish:"October 18th 2017",dateEndFifthStepPublish:"December 18th 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"283266",title:"Dr.",name:"Ricardo",middleName:null,surname:"Loiola Edvan",slug:"ricardo-loiola-edvan",fullName:"Ricardo Loiola Edvan",profilePictureURL:"https://mts.intechopen.com/storage/users/171035/images/6693_n.jpg",biography:"Ricardo Loiola Edvan is doctorate in Animal Science from the Federal University of Ceará 2013, Master's Degree in Animal Production from the Federal University of Paraíba 2010, Specialization in Agroecology from the Federal University of Paraíba 2008, Graduated in Agronomic Engineering from the Federal University of Ceará 2006. Professor of Animal Production, Agronomy and Veterinary Medicine of the Federal University of Piauí acting in the area of Forage and Grassland. Professor of Postgraduate Programs in Animal Science. The Professor coordinates and participates in research and extension projects, articulated with public and private institutions.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Universidade Federal do Piauí",institutionURL:null,country:{name:"Brazil"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"173155",title:"Dr.",name:"Leilson",middleName:"Rocha",surname:"Bezerra",slug:"leilson-bezerra",fullName:"Leilson Bezerra",profilePictureURL:"https://mts.intechopen.com/storage/users/173155/images/6694_n.jpg",biography:"O Professor Leilson Possui Graduação em Medicina Veterinária pela Universidade Federal de Campina Grande (2004), Mestrado no Programa de Pós-Graduação em Zootecnia da Universidade Federal de Campina Grande (2006), Doutorado pelo Programa de Doutorado Integrado em Zootecnia pela Universidade Federal da Paraíba (2009) e Pós-Doutorado em Nutrição de Ruminantes pela Universidade Federal da Bahia (UFBA) e em Biomaterias pela Universidaddel Granada, Espanha. O Professor Leilson Bezerra foi Docente pela Universidade Federal do Piauí de Agosto de 2008 à Janeiro de 2018, onde esteve lotado no Campus Professora Cinobelina Elvas, na cidade de Bom Jesus, onde atua como docente das disciplinas Nutrição de Animais Ruminantes e Bovinocultura de Leite nos Cursos de Medicina Veterinária, Zootecnia e Agronomia. Nos três cursos o Professor orientou diversos discentes em Trabalhos de Conclusão de Curso (TCC), na Iniciação Científica (IC) e tecnológica (IT) com o desenvolvimento de projetos de pesquisa na área de atuação assim como na Extensão Rural, com trabalhos junto a comunidades locais. Atuou também na Coordenação do Curso de Graduação em Zootecnia, além de ter sido Gestor da Fazenda experimental e atualmente e o Assessor de Pesquisa do Campus. Na Pós-Graduação, o Professor participou como Membro Permanente e Coordenador do Programa de Mestrado em Zootecnia e Mestrado e Doutorado em Ciência Animal da Universidade Federal do Piauí e no Mestrado em Zootecnia da Universidade Federal de Campina Grande. Atualmente, é docente da Universidade Federal de Campina Grande, Centro de Saúde e Tecnologia Rural. Além disso, é Bolsista de Produtividade em Pesquisa 2 do CNPq, atuando como Editor Científico e como Consultor ad hoc em vários periódicos internacionais, nacionais e agências de fomento em pesquisa.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Federal University of Campina Grande",institutionURL:null,country:{name:"Brazil"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"305",title:"Plant Genetics",slug:"agricultural-science-plant-genetics"}],chapters:[{id:"56118",title:"Water Harvesting and Soil Water Retention Practices for Forage Production in Degraded Areas in Arid Lands of Mexico",doi:"10.5772/intechopen.69618",slug:"water-harvesting-and-soil-water-retention-practices-for-forage-production-in-degraded-areas-in-arid-",totalDownloads:1678,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The area under arid conditions in Mexico is greater than 50%. This area faces a high risk due to environmental effects. The soil degradation in arid, semi‐arid, and dry sub‐humid areas is of multi‐causal nature, among which climatic and anthropogenic factors stand out. At least, three distinct elements with different effects may be considered: recurrent droughts in short periods, long‐term climate fluctuations, and degradation of soils by human activities. These threaten the productivity and sustainability of ecosystems and agro‐ecosystems. Thus, it is needed to maintain a constant exploration of new and more appropriate technologies that promote the efficient use of natural resources, in a framework of greater sustainability. Many of these technologies are focused toward better management of water and soil resources in production systems. Water management is oriented with rainwater harvesting, efficient irrigation systems, as well as soil moisture retention techniques, and the use of plant species tolerant to water stress. Planting of native species and using soil improvers of edaphic moisture retention can enhance reclamation (recovery) of degraded soils. The aim of this chapter is to show and discuss some experimental results using the above technologies applied to rangelands with degraded soils in dry lands.",signatures:"Aurelio Pedroza‐Sandoval, Ricardo Trejo‐Calzada, Ignacio Sánchez‐\nCohen, Luis G. Yáñez‐Chávez, Adriana Cruz‐Martínez and Uriel\nFigueroa‐Viramontes",downloadPdfUrl:"/chapter/pdf-download/56118",previewPdfUrl:"/chapter/pdf-preview/56118",authors:[{id:"29811",title:"Dr.",name:"Ignacio",surname:"Sánchez Cohen",slug:"ignacio-sanchez-cohen",fullName:"Ignacio Sánchez Cohen"},{id:"204170",title:"Dr.",name:"Aurelio",surname:"Pedroza-Sandoval",slug:"aurelio-pedroza-sandoval",fullName:"Aurelio Pedroza-Sandoval"},{id:"204243",title:"MSc.",name:"Luis Gerardo",surname:"Yañez-Chavez",slug:"luis-gerardo-yanez-chavez",fullName:"Luis Gerardo Yañez-Chavez"},{id:"204244",title:"MSc.",name:"Adriana",surname:"Cruz-Martínez",slug:"adriana-cruz-martinez",fullName:"Adriana Cruz-Martínez"},{id:"204245",title:"Dr.",name:"Ricardo",surname:"Trejo-Calzada",slug:"ricardo-trejo-calzada",fullName:"Ricardo Trejo-Calzada"},{id:"204247",title:"Dr.",name:"Jose Alfredo",surname:"Samaniego-Gaxiola",slug:"jose-alfredo-samaniego-gaxiola",fullName:"Jose Alfredo Samaniego-Gaxiola"}],corrections:null},{id:"56029",title:"Production of Spineless Cactus in Brazilian Semiarid",doi:"10.5772/intechopen.69614",slug:"production-of-spineless-cactus-in-brazilian-semiarid",totalDownloads:1906,totalCrossrefCites:4,totalDimensionsCites:8,hasAltmetrics:0,abstract:"The term “spineless cactus” is used in Brazil to designate cultivars of Opuntia ficus indica Mill and Nopalea cochenillifera Salm Dyck. The spineless cactus was consolidated in Brazilian semiarid as a strategic fundamental food resource in several production livestock systems, constituting a plant with enormous productive potential. Thus, the spineless cactus has been widely cultivated and used for several decades, by enabling the animal feeding in critical periods of year because of its characteristics, morpho‐anatomical and physiological (CAM), which makes it tolerant to long droughts, being a crop that presents high productivity in droughts conditions, when compared to other forages. Nevertheless, the spineless cactus is a crop relatively picky about soil and climate characteristics of region, presenting greater growth in fertile soils, as well as in regions where nighttime temperatures are cool and the air humidity is relatively high. Although the crop be adapted to long droughts periods, many times it’s necessary to perform irrigation in its production system, mainly in regions of low rainfall, for to supply its water needs, thus ensuring productivity and survival of crop. Therefore, the knowledge of characteristics of plant, as well as of appropriate management techniques to crop, is essential for the good performance of spineless cactus.",signatures:"Wilma Cristina Cavalcante dos Santos Sá, Edson Mauro Santos,\nJuliana Silva de Oliveira and Alexandre Fernandes Perazzo",downloadPdfUrl:"/chapter/pdf-download/56029",previewPdfUrl:"/chapter/pdf-preview/56029",authors:[{id:"139631",title:"Dr.",name:"Edson Mauro",surname:"Santos",slug:"edson-mauro-santos",fullName:"Edson Mauro Santos"},{id:"180036",title:"Dr.",name:"Juliana",surname:"Oliveira",slug:"juliana-oliveira",fullName:"Juliana Oliveira"},{id:"203022",title:"MSc.",name:"Wilma",surname:"Sá",slug:"wilma-sa",fullName:"Wilma Sá"},{id:"207265",title:"Dr.",name:"Alexandre",surname:"Perazzo",slug:"alexandre-perazzo",fullName:"Alexandre Perazzo"}],corrections:null},{id:"56095",title:"Development of Tropical Forages in Veracruz, Mexico: Agronomic Approach for the New Forage Legume Cratylia argentea",doi:"10.5772/intechopen.69617",slug:"development-of-tropical-forages-in-veracruz-mexico-agronomic-approach-for-the-new-forage-legume-crat",totalDownloads:1418,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Pastures in the coast of the Gulf of Mexico are characterized by native species (Paspalum spp., Axonopus spp., etc.). These, are limited by productivity due to their low nutritional quality and poor persistence on grazing. The adaptation of new grass and legume species is essential to improve the productivity of animal production. An initial assessment should include the climatic and edaphic adaptation to the region. Species, such as Andropogon gayanus, Pueraria phaseoloides, Centrosema spp., Arachis pintoi, and Cratylia argentea, were evaluated, showing encouraging results compared to native species; our efforts were focused on C. argentea. Several research methods were applied to meet the objectives outlined for each experiment, including methodologies for the establishment of new species. All these trials were subject to rigorous experimental designs, and data were analyzed statistically, using the most adequate programs. These experiences allow us to visualize the most promising materials for the specific conditions of climate and soil. The potential results of this new forage species stand out. Also, these experiments allowed the development of new management practices to improve the productivity of the animal production systems of the region. C. argentea demonstrated its high forage value as a species suitable for silvopastoral systems.",signatures:"Braulio Valles-de la Mora, Epigmenio Castillo-Gallegos, Jesús Jarillo-\nRodríguez, Eliazar Ocaña-Zavaleta and Miguel Angel Alonso-Díaz",downloadPdfUrl:"/chapter/pdf-download/56095",previewPdfUrl:"/chapter/pdf-preview/56095",authors:[{id:"149753",title:"Dr.",name:"Jesús",surname:"Jarillo-Rodríguez",slug:"jesus-jarillo-rodriguez",fullName:"Jesús Jarillo-Rodríguez"},{id:"158862",title:"Dr.",name:"Epigmenio",surname:"Castillo-Gallegos",slug:"epigmenio-castillo-gallegos",fullName:"Epigmenio Castillo-Gallegos"},{id:"201581",title:"Dr.",name:"Braulio",surname:"Valles",slug:"braulio-valles",fullName:"Braulio Valles"},{id:"208059",title:"Dr.",name:"Miguel Angel",surname:"Alonso-Diaz",slug:"miguel-angel-alonso-diaz",fullName:"Miguel Angel Alonso-Diaz"},{id:"208062",title:"MSc.",name:"Eliazar",surname:"Ocaña-Zavaleta",slug:"eliazar-ocana-zavaleta",fullName:"Eliazar Ocaña-Zavaleta"}],corrections:null},{id:"55856",title:"Halophytes as Forages",doi:"10.5772/intechopen.69616",slug:"halophytes-as-forages",totalDownloads:1506,totalCrossrefCites:7,totalDimensionsCites:11,hasAltmetrics:0,abstract:"It is the chemical composition of the halophyte forages and the digestion process of these forages that matter. As the science gets more advanced and the information about these two points becomes clearer, the view of this information might modify our understanding to these processes. Then, some topics might be dropped, and others might be raised or become more obvious. However, the feeding of halophyte forages as per se has several drawbacks and therefore, they have to be fed in mixed rations, fortifying these rations with energy supplements.",signatures:"Salah A. Attia-Ismail",downloadPdfUrl:"/chapter/pdf-download/55856",previewPdfUrl:"/chapter/pdf-preview/55856",authors:[{id:"204190",title:"Emeritus Prof.",name:"Salah",surname:"Attia-Ismail",slug:"salah-attia-ismail",fullName:"Salah Attia-Ismail"}],corrections:null},{id:"57721",title:"An Insight into Current and Future Production of Forage Crops in Zimbabwe",doi:"10.5772/intechopen.71997",slug:"an-insight-into-current-and-future-production-of-forage-crops-in-zimbabwe",totalDownloads:1694,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In Zimbabwe, most livestock are reared by smallholder farmers who live in marginal areas with low rainfall and hence poor forage production. As a consequence, livestock productivity is low and intermittent droughts result in animal mortalities. Forage crops have been widely promoted to provide feed resources to livestock, particularly during the dry season and in years of low precipitation. However, production of forage crops among the smallholder farmers remains low, especially in areas that receive low rainfall (<600 mm per annum). This chapter reviewed work on the production and promotion of forage crops in Zimbabwe in the past 50 years. The production and adaptation of different forage crops viz. improved grasses, herbaceous, and tree legumes to low and high (>800 mm per annum) rainfall areas is highlighted. Planting of improved grasses and herbaceous legumes in fallows and tree legumes as hedges and on contours hold the best promise in terms of improving the availability of forage crops for livestock feeding. Shortage of moisture remains the greatest constraint to increasing the area planted to forage crops. Therefore, the development of irrigation facilities needs to be encouraged to allow for the growing of forage crops.",signatures:"Allan Sebata",downloadPdfUrl:"/chapter/pdf-download/57721",previewPdfUrl:"/chapter/pdf-preview/57721",authors:[{id:"143409",title:"Dr.",name:"Allan",surname:"Sebata",slug:"allan-sebata",fullName:"Allan Sebata"}],corrections:null},{id:"56953",title:"Phosphorus in Forage Production",doi:"10.5772/intechopen.70202",slug:"phosphorus-in-forage-production",totalDownloads:1704,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The aim in developing this work was to summarize information about phosphorus (P) limitation and dynamic in tropical soils for forage grasses production. The major idea is direct information about limited factors affecting P availability, dynamic of P fractionation, P pools, P forms, P use efficiency, and the 4R’s Nutrient Stewardship’ for P-fertilizer in forage grasses. Organizing these sub-headings in a chapter can result in interesting of how P behaves under tropical soils, in order to take decision to manage P-fertilizer to accomplish forage grasses production with social, economic, and environmental benefits. As the most limiting nutrient in tropical soils, P-fertilizer in forage grasses can be more effective if the best management practices are followed. In order to avoid excess P-fertilizer application in soil or P-fertilizer response with low efficiency, it is important to understand the P dynamic and the factors associated with P adsorption in soil. Even with low amount of P requested to forages species, the P available in soil is quite low, and this knowledge is primordial to direct P-fertilizer. Tropical soils are quite limited in P content, due to the natural formation with parental material poor in P content and highly weathering condition. Thus, in order to improve phosphorus use efficiency, the 4R’s must be followed to improve P use efficiency (PUE). It is not easy to improve PUE in highly weathering soil with high buffering capacity; however, all the combination of best management practices for P-fertilizer application can result in better use efficiency. Based on the scarcity of natural P-sources in the whole world, the use of alternative P-sources should be incentivized, and more researches about this issue are need for better understanding.",signatures:"Ademar Pereira Serra, Marlene Estevão Marchetti, Elisângela Dupas,\nCarla Eloize Carducci, Eulene Francisco da Silva, Elaine Reis Pinheiro",downloadPdfUrl:"/chapter/pdf-download/56953",previewPdfUrl:"/chapter/pdf-preview/56953",authors:[{id:"182258",title:"Dr.",name:"Ademar",surname:"Serra",slug:"ademar-serra",fullName:"Ademar Serra"}],corrections:null},{id:"57115",title:"Best Management Practices (BMPs) for Nitrogen Fertilizer in Forage Grasses",doi:"10.5772/intechopen.70345",slug:"best-management-practices-bmps-for-nitrogen-fertilizer-in-forage-grasses",totalDownloads:1620,totalCrossrefCites:2,totalDimensionsCites:4,hasAltmetrics:0,abstract:"There is a concern about the growing population and limitation in natural resources which are taking the population to direct its agricultural systems into a more productive and efficient activity, looking to avoid a negative impact on the surrounding environment. The industry energy expended to produce nitrogen (N)-fertilizer is considered an indirect consumption of energy in agriculture, which is higher with an increasing forage yield. Nitrogen is the key nutrient associated with high-yielding production in forage grass and grain crops. The aim of this chapter is to introduce the best management practices (BMPs) for N-fertilizer application in forage grasses to improve N-use efficiency, since the most economical way to feed livestock is forage plants where its potential biomass production is not well explored. The BMPs basically follow three management practices: (1) soil nutrient availability and forage requirement, (2) fertilizer application, and (3) decrease in nutrient losses from soil. In order to take a decision on applying N-fertilizer to accomplish forage grasses production with social, economic, and environmental benefits, the N-fertilizer use in forage grasses is going to follow the “Right rate, Right source, Right place, and Right time (4R) nutrient stewardship.” The application of the 4R’s nutrients stewardship is directly associated with economic, social, and environmental impact. The capacity of the 4R’s implementation worldwide turns into a best guide to improve the striving of better N-use efficiency in forage grass. The 4R’s are interrelated; thus, the recommendation of N-fertilizer rates cannot be prescribed without the combination of the 4R’s where a whole system to be followed should be considered to decide about N-fertilizer in pasture. Consequently, any decision in one of the 4R’s is going to affect the expected N-fertilizer results and dry matter production.",signatures:"Ademar Pereira Serra, Marlene Estevão Marchetti, Elisângela Dupas,\nSimone Candido Ensinas, Elaine Reis Pinheiro Lourente, Eulene\nFrancisco da Silva, Roberto Giolo de Almeida, Carla Eloize Carducci\nand Alessandra Mayumi Tokura Alovisi",downloadPdfUrl:"/chapter/pdf-download/57115",previewPdfUrl:"/chapter/pdf-preview/57115",authors:[{id:"182258",title:"Dr.",name:"Ademar",surname:"Serra",slug:"ademar-serra",fullName:"Ademar Serra"}],corrections:null},{id:"56079",title:"Alfalfa and Its Symbiosis Responses to Osmotic Stress",doi:"10.5772/intechopen.69760",slug:"alfalfa-and-its-symbiosis-responses-to-osmotic-stress",totalDownloads:1547,totalCrossrefCites:2,totalDimensionsCites:4,hasAltmetrics:0,abstract:"Alfalfa (Medicago sativa L.) is one of the most cultivated forage legumes in Morocco thanks to its great adaptation to the climatic conditions of this country, its high protein content and its ability to fix atmospheric nitrogen in symbiosis with rhizobia. Environmental stresses such as drought and salinity constitute a major factor limiting the symbiotic nitrogen fixation and legume productivity. In the last decades, this process has interested scholars in understanding the implication of these strains in legume stress tolerance in order to make these symbioses more efficient under difficult conditions. Seed osmopriming is a great technique in the amelioration of seed germination and seedlings growth in responses to several abiotic stress conditions. In this chapter, the effects of water deficit on the Moroccan alfalfa populations and their symbiotic association with rhizobia were discussed. Besides, osmopriming could make these symbioses more efficient especially under stress conditions.",signatures:"Mohammed Mouradi, Mohamed Farissi, Abdelaziz Bouizgaren,\nYahya Lahrizi, Ahmed Qaddoury and Cherki Ghoulam",downloadPdfUrl:"/chapter/pdf-download/56079",previewPdfUrl:"/chapter/pdf-preview/56079",authors:[{id:"204044",title:"Dr.",name:"Mohammed",surname:"Mouradi",slug:"mohammed-mouradi",fullName:"Mohammed Mouradi"}],corrections:null},{id:"56047",title:"Genetic Variability of US and Czech Phalaris Arundinacea L. Wild and Cultivated Populations",doi:"10.5772/intechopen.69669",slug:"genetic-variability-of-us-and-czech-phalaris-arundinacea-l-wild-and-cultivated-populations",totalDownloads:1222,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:1,abstract:"The spread of invasive plant species in natural habitats has become a worldwide problem with negative impacts. Phalaris arundinacea, an important forage and ornamental crop, is widespread worldwide. In recent years there has been a massive spread of P. arundinacea across North America and Canada. Production of Phalaris seed as a forage crop occurs in northern Minnesota; seeds are sold throughout the world, particularly in central Europe. We tested genetic similarities and differences between populations in the US (Minnesota) and the Czech Republic using ISSRs to determine potential gene flow for this forage crop. The cultivated forage and wild genotypes were dispersed into two groups that overlapped. At least four sets of wild US genotypes are dissimilar to European counterparts and potentially native to N. America. Future work to prove the ancestry of each accession will be necessary. Nonetheless, the sale of forage cultivars related to or derived from European types causes genetic mixing with N. American types. Part of this intercontinental gene flow is exacerbated by the production of Phalaris forage seed in Minnesota. The implications of these findings for management of invasive crops native to both continents are significant for forage producers, managers, and breeders.",signatures:"Tereza Kávová, Barbora Kubátová, Vladislav Čurn and Neil O.\nAnderson",downloadPdfUrl:"/chapter/pdf-download/56047",previewPdfUrl:"/chapter/pdf-preview/56047",authors:[{id:"69714",title:"Prof.",name:"Neil",surname:"Anderson",slug:"neil-anderson",fullName:"Neil Anderson"},{id:"204381",title:"MSc.",name:"Tereza",surname:"Kávová",slug:"tereza-kavova",fullName:"Tereza Kávová"},{id:"204382",title:"Dr.",name:"Barbora",surname:"Kubátová",slug:"barbora-kubatova",fullName:"Barbora Kubátová"},{id:"204383",title:"Prof.",name:"Vladislav",surname:"Čurn",slug:"vladislav-curn",fullName:"Vladislav Čurn"}],corrections:null},{id:"58077",title:"Sustainable Pasture Management",doi:"10.5772/intechopen.72310",slug:"sustainable-pasture-management",totalDownloads:2021,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Grasslands which are a major part of the global ecosystem, covering 37% of the earth’s terrestrial area, have a significant contribution to food security through providing most of the energy and proteins required by the ruminants used for meat and dairy production. Grasslands are considered to have the potential to play a fundamental role in climate change mitigation, particularly regarding carbon storage and sequestration and for biodiversity preservation. This chapter provides an overview of the causes of the pasture degradation and some essential elements for sustainable management, which aims to improve the quantity and quality of pasture, mitigation of climate change and biodiversity preservation. Another point of this chapter is the grasslands with high nature value that nowadays is a top priority in the European legislation as the European Commission has confirmed that HNV farming will remain a key priority in 2014–2020. 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Optimal insulin delivery requires that accidental intramuscular (IM) or intradermal (ID) delivery be avoided since the pharmacokinetics (PK) and pharmacodynamics (PD) of insulin are significantly altered in these tissue spaces. Optimal delivery also requires that sites of injection or infusion be rotated systematically in order to avoid the most common complication of insulin therapy, lipohypertrophy (LH). Insulin delivered into LH also has significantly altered PK and PD, which can lead to unexpected hypoglycemic episodes and glycemic variability. The latter are associated with worsened overall glucose control, increased short- and long-term complications, and higher costs.
Recently, new recommendations have been published as a consensus document from international diabetes experts [1]. This publication was the collective output of 183 experts from 54 countries who wrote and vetted a practical, evidence-based roadmap for optimal insulin delivery at the FITTER (Forum for Injection Technique and Therapy: Expert Recommendations) workshop from October 23 to 24, 2015, in Rome. FITTER was the fourth in a sequence of workshops on optimal insulin delivery [2, 3, 4]. The FITTER recommendations were also based on the results of the fourth Injection Technique Questionnaire (ITQ) survey conducted from 2014 to 2015. In total, 13,289 insulin-injecting patients from 42 countries participated [5].
Each recommendation is followed by a grade (e.g., A2). The letter indicates the strength of each recommendation: A. Strongly recommended; B. Recommended; C. Unresolved issue. The number indicates the degree of scientific support for each recommendation: 1. At least one rigorously performed study which is peer-reviewed and published; 2. At least one observational, epidemiologic, or population-based study which is peer-reviewed and published; 3. Consensus expert opinion based on patient experience. Since FITTER, many diabetes groups from countries around the world have adapted and adopted these recommendations as local guidelines. We draw on certain of these recommendations in the review that follows as well as summarize studies that have been performed since FITTER and will follow a thematic format, beginning with the anatomy of injection sites.
A large survey of current insulin delivery has shown that there are many aspects of injection practice which are suboptimal [5, 6]. For decades, professionals had been advising patients to use insulin needles which, we now know, were too long for them, with no scientific rationale. However, after the shortest pen needles (4 mm) became available and studies on injection site anatomy and needle performance began to be published, starting in 2010 [7, 8], showing the safety and efficacy of these needles, the recommendations of experts changed. It was recognized that 4-mm pen needles were the optimal choice for nearly all injecting patients, whether adults or children: thin, normal-weight or obese, male or female, and of all ethnicities. These needles were felt to be a key step toward reducing the risk of IM injections. As a result, the use of the 8-mm needle, the dominant size in 2010, has decreased dramatically since then, with a corresponding increase in the use of the 4-mm needle.
However, the latest survey revealed that the longer lengths (8 mm and higher) are still being used by approximately 30% of patients worldwide and that the 5- and 6-mm needles are still used by approximately 20% each. This means that only 30% of patients worldwide currently use the recommended 4-mm needles. Longer needles are being used in sites where IM injection risk is very high (thighs and arms) and by patients who are at an increased risk because they have thin SC layers (slim and normal-weight adults as well as all adolescents and children).
The same survey has shown that lipohypertrophy (LH) is very common at injection sites. LH was found in almost a third of patients worldwide, many of them having LH at multiple injection sites. Injecting into LH has serious consequences for glucose control as well as possibly adverse effects on long-term outcomes and costs. Patients with LH consume a mean of over 10 IU more insulin per day than those without LH, and their HbA1c is on average 0.55% higher. LH is associated with increased rates of unexplained hypoglycemia, glucose variability, and more frequent diabetic ketoacidosis (DKA).
The survey showed that LH is most frequently associated with an incorrect rotation of injection sites and reusing pen needles. Rotating injection sites carefully appears to be the best method of avoiding LH. HbA1c values are lower in patients who rotate their injections over larger injection areas and who get their sites inspected regularly. Checking of injection sites routinely by health-care givers is associated with less LH and lower HbA1c levels, yet nearly 40% of patients reported that they could not remember their injection sites ever being examined. Patients are also more likely to rotate correctly if they have obtained injection instruction from their carer in the last 6 months. However, less than two out of five claim to have obtained such instructions on injecting in that time period. Ten percent of total injectors claim that they have never obtained injection training at all. The survey also shows that incorrect disposal of sharps after use is rampant. The majority of used sharps end up in public trash and constitute a major risk factor for accidental needle sticks.
The skin is the main obstacle the needle must overcome. Needles must be at least long enough to traverse the skin and reach the SC tissue. Adult skin, according to a number of studies using imaging techniques ranging from ultrasound (US) to computer tomography (CT), has yielded remarkably similar results across genders, ethnicities, age groups, and body mass index (BMI) categories. The skin averages approximately 2–2.5-mm thick and varies in its 95% confidence interval (CI) between 1.25 and 3.25 mm. These studies included patients with type 2 diabetes (T2DM) from the Philippines [9], Korea [10], China [11], and India [12]; both type 1 diabetes (T1DM) and T2DM adults from the USA (including four different ethnic groups) [7]; and children from South Africa [13] and Italy [14].
The skin in children is slightly thinner than in adults, but these differences are largely irrelevant for insulin infusions and injections. Skin thickness increases during adolescence and reaches adult size in the late teens.
The SC tissue is the target for insulin. Injections must reach the SC tissue, but not go deeper into the muscle fascia or the muscle itself. Therefore, the thickness of the SC is critical in determining the desired length of the needle as well as the injection technique (e.g., lifting a skin fold or not). SC tissue thickness varies widely depending on gender, site of injection, and BMI. Women, on average, have approximately 5-mm thicker SC fat than men, when one controls for BMI and body site. Truncal sites (abdomen and buttocks) have more SC fat than limbs (arm and thigh), in the same patient. The higher the BMI, the thicker the SC fat. Studies within the last decade have used precision US to determine the SC tissue thickness in a diverse group of adults [7, 9, 15, 16], adolescents, and children [13, 14].
Babies have more SC tissue than preschool children. Children from 2 to 6 years have very little SC tissue regardless of gender. Children from 7 to 13 years gain SC tissue slowly but SC tissue thickness is almost the same in both genders until puberty. At puberty, girls increase their SC tissue more rapidly than boys as a result of hormonal differences.
SC tissue thickness when combined with the currently available needle lengths yields a relatively clear indication of the risk of IM injection. Tables 1 and 2 show the risks for adult and pediatric persons with diabetes, respectively. It is clear from these data that the shorter the needle, the lower the risk of IM injection.
Needle length | Combined | Thigh | Arm | Abdomen | Buttock |
---|---|---|---|---|---|
4 mm | 0.4% | 1.6% | 1.0% | 0.3% | 0.1% |
5 mm | 1.8% | 4.7% | 3.1% | 1.1% | 0.5% |
6 mm | 5.7% | 10.0% | 7.0% | 2.8% | 1.3% |
8 mm | 15.3% | 25.0% | 19.5% | 9.7% | 5.5% |
12.7 mm | 45.0% | 63.0% | 55.0% | 38.0% | 26.9% |
Estimated IM injection risk in adults, by body site*.
Assumes injection straight at 90° without pinch-up (the table adapted from Hirsch [16]).
With kind permission from Hirsch L et al. [16]. Intramuscular risk at insulin injection sites—measurement of the distance from the skin to the muscle and rationale for shorter-length needles for subcutaneous insulin therapy.
Marran, 2014 [13] | Lo Presti, 2014 (pooled) [14] | ||||||
---|---|---|---|---|---|---|---|
4 mm | 27.5% | 12.5% | 12.5% | 0% | 20.2% | 4.6% | 2.4% |
5 mm | 47.5% | 22.5% | 30.0% | 0% | 46.0% | 18.4% | 16.1% |
6 mm | 62.5% | 30.0% | 37.5% | 5.0% | 66.5% | 38.0% | 34.5% |
8 mm | 87.5% | 62.5% | 50.0% | 15.0% | 83.9% | 65.3% | 66.1% |
12.7 mm | 100% | 90.0% | 85.0% | 35.0% | 97.2% | 93.9% | 96.4% |
Calculated risk of IM injection in children and adolescents as a function of injection site, age, and needle length*.
Assumes that injections are into flat skin and not into lifted skin fold.
IM-injected insulins have a much greater variability in absorption and effect (PK and PD) compared to SC-injected. This variability is influenced by both exercise and the properties of the individual insulins. Human insulins and the new analogs also differ as to their PK when injected IM. In general, IM insulin is often associated with a more rapid absorption and unexplained hypoglycemia [17, 18, 19]. Because of the difficulty of predicting the impact of IM injections on PK and PD, various measures can be taken to avoid injecting IM: using of shorter needles, lifting of a skin fold into which one injects the insulin, or choosing injection sites with thicker layers of SC fat. A combination of the above techniques can also be used [20].
In the last decade, insulin needle lengths have decreased dramatically. Previously, adults were given needles that were ≥ 8 mm long and children ≥6 mm. As shown in Tables 1 and 2, these lengths are now universally recognized as too long. They make IM injections more likely, and on the whole, the length of the needle has little or nothing to do with glucose control, according to a multitude of studies [8, 21, 22, 23, 24, 25, 26, 27, 28]. Longer needles also tend to have larger diameters (smaller G or gauge), which correlates with a greater injection pain.
Hirsch [8] compared the 4-mm pen needle to 5- and 8-mm needles and showed the former to be safe and efficacious in adults (i.e., comparable glucose control); leakage from the skin was equivalent and both pain scores and overall preference were better with the 4 mm. In Japan, Miwa [29] compared the 4-mm needle with 6 mm and showed equivalent results, as did Nagai [30] when comparing 4-to 5-mm pen needles. Hirose [31] found equivalent modeled PK/PD results for the 4 mm compared to the 6- and the 8-mm needles, in young non-diabetics. Birkebaek [32] found a reduced IM risk with 4 versus 6-mm PNs in children and lean adults. Lo Presti [14] measured the skin and SC in children and adolescents with diabetes (ages 2–17) and concluded that the safest needle length for all ages is the 4 mm.
In obese adults, Bergenstal [33] recently showed that the 4-mm pen needles deliver equivalent glycemic control (HbA1c) to both 8- and 12.7-mm pen needles. These obese patients were taking relatively high doses of glargine (>40 IU), with total daily dose (TDD) insulin up to 300 U daily. No differences between 4- and both 8- and 12.7-mm PNs in hypo- or hyperglycemic events or insulin leakage were found in obese subjects with BMI up to nearly 60 kg/m2. The 4-mm needle was found to be less painful, easier to use, easier to insert, and less anxiety-provoking than 8 or 12.7 mm (all at p < 0.05).
Based on these studies, FITTER recommended the following:
The 4-mm needle inserted perpendicularly is long enough to penetrate the skin and enter the subcutaneous tissue, with little risk of intramuscular (or intradermal) injection. Therefore, it should be considered the safest pen needles for adults and children regardless of age, gender, ethnicity, and BMI.
The 4-mm needle should be inserted perpendicular to the skin (at 90° to the skin surface), not at an angle, regardless of whether a skin fold is raised. A1.
Very young children (6 years old and under) and very thin adults should use the 4-mm needle by lifting a skin fold and inserting the needle perpendicularly into it. Others may inject using the 4-mm needle without lifting a skin fold. A1
Patients with tremors or other disorders, which make them unable to hold a 4-mm pen needle in place, may need longer needles. B3
Recommended injection sites include the abdomen, lateral thigh, arms, and buttocks [34, 35, 36, 37, 38]. In the abdomen, injections or infusions in adults may be given within the following boundaries: 1 cm above symphysis pubis, 1 cm below the lowest rib, 1 cm away from the umbilicus, and laterally at the flanks. In the lateral thighs, patients should use the upper third anteriorly. The posterior lateral aspect of the upper buttocks and flanks may be used. In the arm, one may use the mid-third posterior aspect. In children, the abdominal boundaries are similar to adults, but 2 cm is used instead of 1 cm for all distances. A degree of clinical judgment must be used in all cases, adult and pediatric.
Soluble human insulin (e.g., regular insulin) has a slower absorption profile than the rapid-acting analogs (lispro, aspart, and glulisine). The PK and PD of regular insulin, as well as those of neutral protamine Hagedorn (NPH), are highly dependent on the body site injected and the technique used. FITTER recommendations state that:
IM injections of NPH and long-acting insulin analogs must be strictly avoided due to the risk of hypoglycemia [17, 39, 40, 41].
The abdomen is the preferred site for soluble human insulin (regular), since absorption of this insulin is fastest there [35, 42, 43, 44, 45, 46].
The regular/NPH mix should be given in the abdomen to increase the speed of absorption of the short-acting insulin in order to cover postprandial glycemic excursions [18].
If there is risk of nocturnal hypoglycemia, NPH- and NPH-containing mixes given in the evening should be injected into the thigh or the buttock as these sites have slower absorption of NPH [38, 47, 48].
There are fewer studies of optimal delivery methods for the newer insulin analogs and GLP-1 s. However, insulin analogs are
Rapid-acting insulin analogs may be given at any of the injection sites, as absorption rates do not appear to be site-specific [49, 50, 51, 52, 53].
Rapid-acting analogs should not be given IM although studies have shown that absorption rates are similar from fat tissue and resting muscle. Absorption from working muscle has not, however, been studied [50, 51, 54].
Pending further studies, patients may inject long-acting insulin analogs in any of the usual injecting sites, with appropriate technique to prevent IM injection which can lead to profound hypoglycemia [55].
LH is the most common complication of insulin injection [59, 60, 61, 62] or infusion [63, 64], with prevalence rates of 50% or higher. Risk factors for LH appear to be longer time on insulin, more daily injections, failure to carefully rotate injection sites, and extensive reuse of needles [59, 65, 66, 67, 68]. The latter two risk factors are modifiable. Insulin injected into LH has been reported to have delayed or erratic absorption which may worsen glucose control, although these trials are older with less rigor, less precise insulin assays, or very small sample sizes which in one case led to a conclusion that injecting into LH did not worsen inherent variability of insulin uptake [69, 70, 71, 72]. A crossover glucose clamp study [73] showed that both insulin absorption and action when injected into LH are blunted and are 3–5X more variable than when the same insulin dose is injected into non-LH areas. A controlled mixed-meal tolerance test in the same study also showed a reduced insulin absorption, and prolonged postprandial hyperglycemia when the insulin was injected into the LH area. When patients change from delivering insulin into LH and move to normal tissue, they are at risk of hypoglycemia and must lower their doses. Gentile [74, 75] has shown convincingly that HCPs trained to detect LH can do so with extremely high efficiency using the physical examination alone, achieving up to 97% consistency levels. FITTER issued the following recommendations:
Switching injections from lipohypertrophy to normal tissue often requires a decrease in the dose of insulin injected. The amount of change varies from one individual to another and should be guided by frequent blood glucose measurements. Reductions often exceed 20% of their original dose [66, 76].
Injections should be systematically rotated in such a way that they are spaced at least 1 cm (or approximate width of an adult finger) from each other in order to avoid repeat tissue trauma.
One scheme with proven effectiveness involves dividing the injection site into quadrants (or halves when using the thighs or the buttocks), using one quadrant per week and moving quadrant to quadrant in a consistent direction (e.g., clockwise) [77].
A multicenter interventional study in the UK [78] showed that education focused on these recommendations resulted in significantly reduced clinically detectable LH after 6 months, with LH either disappearing completely or decreasing by approximately 50% from its original size. The mean HbA1c fell by more than 4 mmol/L, and there were significantly reduced levels of unexpected hypoglycemia and glycemic variability. The mean TDD of insulin in the study population fell by an average of 5.6 IU by study close.
In a controlled, prospective, multicenter study in French patients [79], all of whom had LH, the intervention consisted of instructions to move injections to non-LH areas, to correctly rotate within injection sites, to forego needle reuse, and to switch to 4-mm needles in order to facilitate correct rotation without increased IM injections. These patients were also given intensive education on the injection recommendations as summarized in this chapter. Control patients were informed of the presence of LH and were told that injections should not be given into LH. They received usual and standard education. In the intervention group, there was a significant decrease of TDD of insulin of approximately 5 IU versus baseline (P = 0.035). There were significant decreases in HbA1c (up to 0.5%) in both intervention and control groups, with no significant differences between groups. A significant number of intervention patients improved their IT habits. The authors concluded that the intervention was effective in both groups, but that intensive education in LH management yielded more rapid and superior outcomes.
An interventional study in Moscow [80] followed three groups of T1DM and T2DM patients for 6 months. Two groups received structured injection training (with one group receiving 4-mm needles for each injection while the other did not) and a control group which did not get training or needles. Both training groups had HbA1C reductions of approximately 1% but the non-training group saw no change. Needle reuse and LH declined in the training groups and injection technique improved but none of these changes were seen in the non-training group.
The available data from intervention trials in patients with insulin-related LH show consistently positive outcomes. However, there are limitations to each trial—some were not randomized; in another, the control group received meaningful parts of the educational intervention [79]. Results of one or more ongoing randomized clinical trials should provide more definitive answers to the impact of injection technique training in the near future.
Reusing needles is a common practice of injecting patients, mainly for reasons of convenience and cost-saving. However, a number of studies have linked needle reuse to LH [59, 65, 66, 81, 82, 83], especially when the reuse is excessive (≥5 times/needle). Injection pain was associated with reuse in one study [84] although another one disputed these results [85]. Another study found bacterial growth on reused needles and inflammatory changes (skin redness) at injection sites of patients who reused needles [86, 87]. Although local infections or abscesses have not been reported with needle reuse, FITTER recommends against reusing needles, which are labeled by regulatory agencies for single use.
Patients should never share insulin pens, whether in the hospital or at home setting. Blood can be aspirated back into the pen cartridge even after one injection, and this could possibly transmit a blood-borne disease such as HIV or hepatitis to the next user. Sonoki [88] found hemoglobin in a number of cartridges which patients had used only once. Le Floch [89] also studied the contamination of cartridges after one use and found similar findings. A recent US study corroborated these findings [90]. The rule with insulin injections is clear: one patient/one insulin pen.
Insulin needles are the most commonly used sharp worldwide. If not disposed of properly, needle-stick injuries with used insulin needles could transmit hepatitis, HIV, or other blood-borne pathogens. This is a major public health issue. Technologies exist to minimize this risk. FITTER recommended the following to minimize the risk of needle-stick injuries, particularly in a hospital or other inpatient setting:
Safety-engineered devices play a critical role in protecting injectors, pump users, and downstream workers [91].
Needle recapping should not be done.
Sharp containers must be easily accessible at the point of care beside the patient, prior to the injection or infusion.
Safe disposal should be taught to patients, caregivers, and all others who may come in contact with the sharp device from the beginning of injection or infusion therapy and reinforced throughout [92]
Under no circumstance should sharps material be disposed of into the public trash or rubbish system.
Continuous subcutaneous insulin infusion (CSII) has been used for 40 years [93, 94]. Insulin infusion sets (IISs) deliver insulin into the SC, and they have been associated with numerous adverse side effects [95]. It is generally agreed that if a patient has otherwise unexplained hyperglycemia, they should administer a correction bolus via their pump. If the blood glucose does not decline at least 50 mg/dL by 90 min, they should (1) remove the set, (2) give a correction with a pen or a syringe, and (3) insert a new set. FITTER recommended the following additional recommendations for CSII and IIS users:
CSII cannula should be changed every 48–72 h in order to minimize infusion site adverse events and potential metabolic deterioration. However, these times are very patient-dependent and should be adjusted accordingly.
All CSII patients should be taught to rotate infusion sites along the same principles that injecting patients are taught to rotate injection sites.
Any CSII patients with unexplained glucose variability including frequent hypoglycemia/hyperglycemia should have infusion sites checked for lipohypertrophy, nodules, scarring, inflammation, or other skin and SC conditions that could affect insulin flow or absorption.
Insulin has a very low therapeutic index. The margin between its greatest therapeutic benefit and its unacceptable side effects is low. Without careful attention to optimal insulin delivery, patients can find themselves on either side of a slippery slope: either suboptimal therapeutic benefit or high toxicity. Optimal insulin delivery is complex and involves choices that patients and professionals may not have previously considered: the choice of injection sites as a function of the insulin delivered, the choice of needle length as a function of SC thickness, the injection or infusion technique which ensure consistently effective SC delivery, the precise and systematic rotation of delivery sites, reduced or non-reuse of sharps, and safe disposal of used sharps which reduces needle-stick injury risk to family members or the community at large [96]. We have provided both evidence-based recommendations and proof that these work in practice and deliver insulin with an improved therapeutic index and better outcomes—both clinical- and patient-reported. The challenge now is to scale these recommendations so that all insulin-using patients and insulin-prescribing professional know and follow them.
Authors KS and LH are employees of BD, a manufacturer of injecting devices. All other authors declare that they have no conflict of interest.
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
BMI | body mass index |
CSII | continuous subcutaneous insulin infusion |
DKA | diabetic ketoacidosis |
FIT | Forum for Injection Technique |
FITTER | Forum for Injection Technique and Therapy: Expert Recommendations |
G | gauge (of needle). |
GCP | good clinical practice. |
GLP-1 | glucagon-like peptide-1 receptor agonists |
HbA1c | glycated hemoglobin |
HBV | hepatitis B virus |
HCP | health care professional |
HCV | hepatitis C virus |
ID | intradermal |
IM | intramuscular |
ITQ | injection technique questionnaire |
IU | international unit (of insulin) |
LH− | patient without lipohypertrophy |
LH | lipohypertrophy |
LH+ | patient with lipohypertrophy |
NPH | neutral protamine hagedorn (also known as insulin N) |
NSI | needle-stick injury |
PD | pharmacodynamics |
PK | pharmacokinetics. |
SC | subcutaneous |
T1DM | type 1 diabetes |
T2DM | type 2 diabetes. |
TDD | total daily dose (of insulin) |
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