Galen is a United Kingdom company which obtained the rights to Synera in July This gives Synera a real chance for a fresh start. Galen seems to be taking advantage of this fresh start, although things happen slowly in this area. Published medical studies have shown this patch to be much more effective than other anesthetic creams and patches for needle procedures.
In addition, the the dual action of the warming effect of the patch plus the vasodilation of the tetracaine component makes veins much easier to access during needle procedures. In the United States, the Synera patch is currently available by prescription but not yet easily available. Although very few doctors know about Synera and only a few hospital and specialty pharmacies have Synera patches in stock , any United States licensed physician may purchase the Synera patch or write a prescription for their patient to use the Synera patch.
Synera patches are nearly always a special order item from a conventional pharmacy, and it can be a one or two week process to obtain it from a local pharmacy. Physicians can now also prescribe Synera for delivery directly to the patient's home. The manufacturer of the patch had been somewhat constrained by the FDA-approved labeling which initially required that it be used only in a medical setting; but in June of , the U.
Food and Drug Administration approved Synera for home use. In Europe, where the patch is marketed as Rapydan, the marketing has in recent years been done by EuroCept, and the availability may vary greatly from country to country, although the Rapydan patch has been approved for use in the United Kingdom and throughout the European Union.
It is not clear how the purchase of U. Nuvo Research, which was a former owner of Synera and which still owns most of the rights to Synera, entered into marketing contracts for Synera with a distributor in Canada and has applied to the Canadian government authorities to license the Synera patch for sale in Canada.
It is very clear, however, that Nuvo Research still does not understand what an important and revolutionary product that they have. Unfortunately, it doesn't matter how good the product is if patients cannot obtain it. See the Synera web site. This patch is still very difficult or impossible to obtain in many other countries. British Journal of Anaesthesia.
EMLA is a mixture of lidocaine and prilocaine that is a liquid at room temperature, even though both lidocaine and prilocaine are room-temperature solids. This is what is meant by eutectic. Another common eutectic mixture is solder, which has a lower melting point that its constituent metals. The liquid penetrates much more deeply than ordinary anesthetic solutions. EMLA is rather messy and must be applied at least one hour before the needle procedure. Any pharmacy can get EMLA easily, but most United States pharmacies except for hospital pharmacies do not keep it in stock.
Although EMLA is available without a prescription in Canada, Canadian pharmacies now require a prescription from United States residents ordering by mail order or on the web. EMLA cream should be applied one hour before the needle procedure. Some individuals may require more time, and many people find the process to be rather troublesome and messy, and many find it to be not very effective. The effectiveness of EMLA cream varies greatly from individual to individual.
EMLA works fairly well for many people whose needle phobia reaction is triggered by the sensation of the needle going in. EMLA does not work well for most people whose primary problem is an acute sensitivity to pain. An EMLA patch is also available in many countries. EMLA is one of the older and less effective solutions for needle phobia. Its main advantage is that, since it has been around longer, more doctors know about it, and it is generally easier to obtain that other options that are likely to be much more effective.
A disadvantage of EMLA is the vasoconstriction it causes, which can make your veins more difficult to access. Although a prescription is required for United States residents purchasing EMLA, there is no reason for a doctor to be reluctant to write you a prescription for this unless you are one of the rare people with an allergy to one of the ingredients.
If your doctor doesn't take your needle phobia seriously, find another doctor. For most people, the 30 gram tubes of EMLA cream offer the most convenience and flexibility. Use caution about where tubes of EMLA cream are stored. There have been cases of people especially young children confusing EMLA cream with toothpaste, sometimes with serious results. Even within the United States, medical personnel are more likely to be familiar with EMLA than with much more effective topical anesthetics such as the Synera patch. Tetracaine is also known as amethocaine, and is sold under a number of brand names in various countries.
Tetracaine has the additional advantage over EMLA that it will dilate veins, making them easier to access.
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This is in contrast to EMLA, which contains prilocaine, which is a vasoconstrictor, and can therefore make access to veins more difficult. A topical 4 percent tetracaine gel sold under the brand name Ametop is available in many countries, but not in the United States. Ametop generally takes from 30 to 60 minutes after application to achieve effectiveness for needle procedures. L-M-X 4 is not specifically approved for needle procedures, but some test reports have indicated that it is nearly as effective as EMLA.
Most reports indicate that L-M-X 4 is much more effective than other forms of topical lidocaine. For reasons that I don't understand, most needle phobics are unwilling to even try L-M-X 4. They may have the mistaken impression that it is not as effective as EMLA because it doesn't require a prescription in the United States. A company called Echo Therapeutics has made a device that appears to make L-M-X 4 dramatically more effective. Echo Therapeutics has entered into an agreement with the makers of L-M-X 4 to develop the product combination.
Much will depend upon FDA regulatory approval and whether Echo Therapeutic follows a rational marketing policy, or whether they will decide instead to follow other companies into the graveyard of companies that have produced effective products that were kept forever out of the reach of needle phobics.
All of the anesthetic creams mentioned above should only be applied to a small area where the needle procedure is to be done.
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They all need to be applied in a rather thick layer, and they must be left on for 30 to 60 minutes. For most people, these creams will not produce total numbing, but will usually be quite helpful. If you don't already know, find out in advance on what part of your body the needle procedure will be done.
There have been some people who have suffered severe adverse effects from using these creams over a very large area of their body. Also, keep these creams out of reach of the unsupervised use by children. There have been severe adverse effects from young children mistaking these anesthetic creams for other products such as toothpaste.
The anesthetic creams are very helpful for most people, but do not reduce sensation as much as the newer products such as the Synera patch. This is very unfortunate because, at one time, these units were the basis of the most effective technique for conquering needle phobia. None of the three major manufacturers of the lidocaine-based iontophoresis units really understood the nature and magnitude of the needle phobia problem, and they all insisted on marketing their products to the very people who considered them to be unnecessary.
Like EMLA, ice works for some people whose reaction is triggered by the sensation of the needle going in, but it does little for acute sensitivity to pain. A relatively large dose may be needed, depending on the severity of the needle phobia, but eventually the anti-anxiety agent may become unnecessary as the brain learns to avoid the needle phobia reaction.
Do not drive while under the influence of a large dose of an anti-anxiety agent. These anti-anxiety medicines must be used as directed by a physician, but they can be very effective, especially for those whose main problem is fainting the vasovagal reflex reaction. Some patients must lie with with legs elevated and their head lowered.
The patient must be encouraged to remain lying or sitting until he feels quite comfortable slowly standing up. There have been a number of scientific tests of beta blockers for vasovagal reflex, but the results have been very inconsistent. Beta blockers do seem to be very useful for some people, though. The older beta blockers, such as propranolol Inderal and atenolol Tenormin are very inexpensive and very safe especially when used only occasionally. When used only intermittently in healthy people, they are almost completely free of side effects. Beta blockers are most commonly used as blood pressure medications, but they have many other uses.
One big advantage of beta blockers over other medications is that they rarely have any significant effect on thinking and reaction time. So, unlike large doses of tranquilizers or anti-anxiety medications, beta blockers usually don't usually affect your ability to do things like driving. Be careful about standing up too quickly when you are on a large dose of a beta blocker, though.
Standing up too quickly can cause "postural hypotension. If you are considering the use of both lidocaine and a beta blocker, you need to be aware that there have been some rare reports of interactions between these two medicines. In some people, beta blockers can increase the severity of allergic reactions. Nitrous oxide is probably the safest and most convenient anti-anxiety agent, especially for milder cases of needle phobia. Unfortunately, nitrous oxide is rarely available in doctor's offices.
There are reports that a few hospitals are finally beginning to make nitrous oxide available for use during needle procedures, although they are restricting the use of nitrous oxide in hospitals mainly for use in children only. Nitrous oxide could be one of the most useful agents for needle phobia if it were used properly.
This is especially true for the mixture of nitrous oxide and oxygen, which makes a very safe anesthetic for needle procedures. Nitrous oxide has a very rapid time of onset of action and a very rapid return to normalcy after it is withdrawn from the patient. Unfortunately, it is very seldom used for needle phobia outside of dentistry.
In the United States, a very curious situation exists with regard to nitrous oxide. Many dentists in the United States are able to use nitrous oxide on their patients with only a single dental assistant to help them with the process. Medical clinics and hospitals in the United States have generally judged themselves to be incompetent to use nitrous oxide. In many other countries, however, the mixture of nitrous oxide and oxygen is commonly available in clinics and hospitals.
Relatively inexperienced nurses should gain their experience on non-needle-phobic patients. Also, be aware that problems with any of the apparatus during venipuncture are likely to unduly panic a needle-phobic patient. Such problems may even cause a relapse among patients who have overcome their needle phobia. Consider temporarily aborting the procedure if problems are encountered with any of the equipment during procedures performed on a needle phobic patient.
Needle phobics need to make a conscious attempt to breath deeply and slowly. This cannot be emphasized enough.
Many needle phobics have preferred locations for a needle insertion. Get the injection at a doctor's office. Let the nurse know that you are needle phobic, and get the injection while your are sitting or lying down.
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Don't get up too quickly. Stay in the doctor's office for fifteen minutes or so after the injection. The physiological needle phobia reaction sometimes doesn't occur until a few minutes after the injection. Muscles should be contracted over as much of the body as possible, but relaxed in the area of the body receiving the needle procedure. Unfortunately, I have not been able to find a good description of the technique in readily available articles.
Most of what has been written about the technique is in medical journal articles that require a significant payment just to read the article online. People who are interested in pursuing this further can do a search for "applied tension" on PubMed. Open source PDF readers such as the one in the Firefox web browser may not reproduce these files clearly.
One thing of particular importance, especially for needle phobics with a tendency to faint, is keeping well-hydrated before the needle procedure. Many blood tests require no food or beverage intake for several hours before the test. Unless the medical people specifically tell you otherwise, though, it is vital to continue to drink water before the test.
You must not only drink enough water to replace your normal fluid intake, but you must also replace the water content that you would normally get from the water content of food. Dehydration just makes fainting more likely. Some devices are on the market that use the "gate control" method of nerve signal interference. These devices use vibration, or vibration combined with cooling, to block the nerves from transmitting to the brain the sensation of the needle entering the body.
These devices seem to be very effective in many children and in adults with milder forms of needle phobia. Pictured on the right is Buzzy , which is the only one of these gate control devices that is currently available without a prescription. Buzzy was developed with the bee image for children, but a plain version is also available for adults. The wings on the Buzzy device contain a gel that is designed to be frozen solid in the freezer before use. Buzzy is placed near the injection site with the injection site near the tail of the bee , but with Buzzy between the injection site and the brain.
Buzzy combines the use of cold and vibration to block the sensation of the needle procedure. There are other "gate control" devices that are only sold directly to medical professionals that are designed to be used more directly in conjunction with the injection device. The Buzzy device, on average, only eliminates about half of the needle sensation and pain, but that may be enough to make a very big difference for many people. The Buzzy device is becoming available in many other countries besides the United States. For residents of the United Kingdom, there is now a Buzzy web site for the U.
Click on the Buzzy 4 Shots link at those sites. See the Buzzy International Orders Page. Unfortunately, as of the beginning of , sales of Buzzy are still not permitted in Canada. The Synera patch is available in the United States and is becoming available in most countries in Europe where it is sold under the name Rapydan. It requires a prescription, but most doctors have never heard of it. This is a good opportunity for patients to educate their doctors about needle phobia and about the things that are available for needle phobics.
The patch may not numb deeply enough for intramuscular injections; but it should help a little, and every little bit helps. Many needle phobics find the Synera patch life-changing for blood tests and other intravenous procedures. The fact that Synera is not available in Canada is solely due to regulatory obstruction on the part of Health Canada.
Fear of needles
Applied Tension seems to be a good technique to prevent fainting. Applied Tension is a technique that does require some practice, though. It is a technique that you can practice doing at home, however, when you are not actually facing a needle procedure. Applied Tension may also be useful to those who tend to lose consciousness when watching or listening to descriptions of medical procedures.
In spite of the fact that the physiological vasovagal reflex reaction is rather consistent, there are individual differences in the subjective perceptions of needle phobics; and many needle phobics have other reactions, and do not experience the vasovagal reflex reaction at all. The best techniques to use to prevent a needle phobia reaction vary greatly from individual to individual.
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These individual differences must be taken into account when choosing a solution. Hamilton's article, the clinical findings associated with the vasovagal reflex reaction include: Physical symptoms of syncope fainting , near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms, e. Electrocardiogram anomalies of virtually any type. Rises in any combination of several stress hormones: Difficult to access veins: Many people who would otherwise have mild or moderate needle phobia have their condition made much worse because of having veins that are difficult to access.
Many people have smaller or deeper veins than normal, others have veins that tend to "roll" or break during needle procedures. There is no longer any excuse for this to happen to anyone because of the recent development of devices for imaging veins. A number of such devices are available. One of the most sophisticated is the Vein Viewer as shown in this YouTube video animation. There are several YouTube videos of this device, and some of them show actual needle procedures, but the one linked here does not. The Vein Viewer is made by Christie Digital.
The Vein Viewer is a more sophisticated device that is intended for sale to hospitals and doctor's clinics. There are much less-sophisticated and lower-cost devices available, though. One of the most common is the hand-held Veinlite , which is available to both patients and medical professionals from many medical supply stores. There are several versions of the Veinlite available, with the simplest version available from some sources for less than United States dollars. Those who wish to learn more about needle phobia are encouraged to read the article by Dr. The Journal of Family Practice is available in any medical library.
Most cities have at least one hospital with a medical library that is available to the public. Many people have recently been having a very difficult time finding this article since most libraries are no longer keeping older issues on the shelves. Most medical libraries that no longer have issues on the shelves usually do have these issues available on either computer or microfilm, especially the larger university libraries. Here is the information about that article once again: I am not aware of any complete copies of Dr.
Hamilton's comprehensive article on needle phobia that are available on the web. If you have access to a University medical library, you can find the original article using the following citation: James Hamilton August Journal of Family Practice 41 2: Showing a copy of Dr. Hamilton's article from the Journal of Family Practice to your physician may encourage him to take your needle phobia more seriously.
I cannot emphasize the importance of this enough. Often, the only way to convey new medical information to a physician is to show the physician a copy of an article from a respected medical journal. You may be surprised how often this can make a real difference in your treatment. Every time that you successfully educate a medical professional about needle phobia, you will be making life better for yourself and for many other needle phobics, as well.
Another very useful article from the Journal of Family Practice about the medical experiments with needle phobia that were done on Dr. Hamilton is no longer available on the web. During those tests, which were reported in a article, Dr. That article is available through medical libraries using the following citation:. Journal of Family Practice 32 4: The only way that any progress is going to be made against needle phobia is if those who suffer from this condition educate the medical profession about this condition. Do not sit back and wait for a course in Needle Phobia to suddenly be taught at the Harvard Medical School.
This just isn't how things happen. This isn't the way that medical professionals find out about the conditions that they are currently ignoring. Information about needle phobia will only come to the medical profession from those who are suffering from the medical condition and from their loved ones. Doctors and other medical professionals need to be politely educated about the nature of needle phobia and its treatments.
Unfortunately, it is up to patients with needle phobia to educate themselves about this condition, and then to convey that information to their physicians. I keep repeating this over and over for a very good reason, but few hear me. Those who suffer from needle phobia need to learn from those who have suffered from conditions such as breast cancer and AIDS. The recognition of the importance of an ignored major medical condition usually begins with the patients, not with the medical profession.
This important fact deserves repeating again: Among the large amount of email that I receive, a very small percentage come from needle phobics who have developed a high level of anger toward the medical profession. This anger, although often entirely understandable, is extremely counterproductive in our efforts to politely educate the medical professionals about needle phobia. If you are one of these individuals, please try to find a way to overcome your anger before you become a Needle Phobia activist. If you have developed hostility and anger toward the medical profession, you may find it very useful to have several sessions talking this over with a psychiatrist.
A psychiatrist is a medical doctor who is trained to discuss and to help you to understand these types of problems. Considering the brutal way that many very young children are treated during needle procedures, it is not surprising that many people develop this hostility. Someday, though, you are likely to reach a point where your health, and possibly your life, depends upon these medical professionals.
So if you feel this hostility, please take steps to overcome it before you develop a serious medical problem where you desperately need medical professionals. You must learn to deal with medical professionals assertively , without being aggressive. It is a sub-type of blood-injury-injection phobia, which is sometimes called B-I-I phobia. It is also listed in DSM-5 the fifth edition. It is very briefly discussed on pages and of DSM The standard ICD medical insurance code for injection and transfusion phobia is F ICD medical insurance codes are in use in much of the world, but have been repeatedly delayed in the United States.
This page contains a considerable amount of information packed into a single long page. If you are suffering from needle phobia, please re-read this information carefully more than once. I do read all of my email, and for more than 19 years I tried to answer as much as possible, but at least half of the email that I receive asked me questions that are answered on this web page. Many people are understandably very emotional when they are reading about this subject.
Please re-read this page until you can absorb all of the information calmly. I know that this is a very long page, and it can be very difficult, at first, to sort out which parts of this page apply to you. I had to put everything on a single long page because that is the only way that I could allow each individual reader to select what is relevant to them.
The Needle Phobia Page - fear of needles and needle procedures
Unfortunately, I do not know of any physicians offering help or treatment for this condition. I would very much like to develop a list of physicians who treat needle phobia; but that list does not yet exist, and I doubt that it will at anytime in the foreseeable future. Physicians who make special provisions for needle phobic patients are desperately needed. There are some dentists who offer considerable help with dental needle phobia.
I am asking doctors who are interested to contact me at the email address shown below. I do keep this site updated frequently; and after more than 19 years, there are still no practicing physicians who specialize in helping patients with needle phobia. Unlike a psychologist, a psychiatrist is a medical doctor who can prescribe medicines like Valium and anesthetic skin patches like Synera.
Psychiatrists are generally much more comfortable prescribing such medicines, and they are much more knowledgeable about the use of anti-anxiety medicines than other physicians. I have heard from psychologists who claim to be able to treat needle phobia successfully, but nearly all needle phobics who report going to a psychologist report negative results. The number of needle phobics who have emailed me reporting unsatisfactory results from sessions with psychologists is extremely large. I am particularly concerned about what might happen in a non-medical setting if someone experiences a severe vasovagal reflex reaction as many people do when talking about needle procedures.
Psychologist may have much more success with needle phobia if they learn to separate those with vasovagal fainting needle phobia from the recently skyrocketing number of needle phobics created by uncaring or careless medical practices, especially with regard to young children. Hamilton is retired and is not in private practice. In past years, he has seriously considered writing a book on needle phobia. Other matters have stood in the way of completing such a book. Some companies have, or are developing, products with the potential to dramatically improve the lives of millions of needle phobics.
Echo Therapeutics has developed products for needle-free glucose monitoring and drug delivery that are not yet on the market. It remains to be seen whether either of these companies will market their products in such a way that they will ever become easily available to needle phobic individuals. Most companies still insist upon marketing their products exclusively to the people who believe that such products are unnecessary in spite of the millions of dollars that have already been tragically wasted on such efforts.
A few needle phobia sufferers want to know the Greek name for needle phobia. Some people argue over the correct Greek term for the disorder. I am not a Greek scholar, and neither are the scientists who have studied needle phobia. The Greek terms for most phobias cannot be found in most medical databases. The correct medical term for needle phobia in all English-speaking countries is needle phobia. For those who are curious, there is a separate page about odd names for needle phobia. Copies of this page may be made for any non-commercial use as long as the copyright notice is included.
It may be especially useful for patients to take a copy of this page to their physicians. The only way that needle phobia is ever going to be taken seriously by the medical profession is if needle phobics take charge of the situation and insist that provisions are made for their needle phobia. This page is for informational purposes only. It is not intended to provide any specific medical advice. Futurescience, LLC is a one-person company that is trying to educate people about critical areas of science and medicine that have all too often been overlooked. Jerry Emanuelson's email address is: I do read all of my needle phobia email, but in recent years the volume of this email has become so enormous that I have no hope of ever being able to respond to more than a small fraction of it.
I am just one person fighting a losing battle. I have had to stop responding to most individual requests for help. The needle phobia problem is just too overwhelming for one person to handle, especially with very little financial support. I want to thank the readers of this page for withholding most of their requests for personal help during the past two years.
It has been nice to finally have some time for myself. I will continue to try to make relevant additions and other improvements to this page. I hope soon to be able to, once again, begin responding to most of my email. This page is available in several ways, but if you link to this page, please use: Donations to the Needle Phobia Page.
I am now trying to get by on a monthly Social Security check plus some occasional electronics consulting and freelance science writing work. Reader donations through PayPal will allow me to further develop this site and continue its operation. Donations are processed through PayPal, and I never see any of your credit card information. Donations received during totalled dollars.
This made the first year that donations have been able to cover all of the operating expenses of the Needle Phobia Page. This is huge increase over the prior year , when donations totalled dollars. I may have missed personally thanking everyone who made a donation, but I sincerely appreciate every single donation. I hope that this page can continue to make a positive difference in the lives of people suffering from needle phobia. Although there is a lot of specific product information on this page, in the past, it has never earned a penny from paid advertising.
I would very much like to have advertising of products that are both relevant and effective. As of March 28, I began to explore a direct affiliate relationship with the makers of the Buzzy device. This may prevent the total reliance on donations mostly out of my own pocket that has historically supported the Needle Phobia Page. This confirms the impression that I have had for a long time, judging from my email, that it is often very difficult to induce needle phobics to actually take specific actions to alleviate their needle phobia.
Needle phobia is often accompanied by a large degree of learned helplessness. Important information regarding your donation: The Needle Phobia Page is not yet a part of any non-profit corporation or non-profit foundation. This web site was developed by me in , and it is maintained by Futurescience, LLC, which is just the legal entity under which I do this kind of work. No one else is involved except me. I would like to eventually make the Needle Phobia Page into the web presence of a non-profit organization to conquer needle phobia; but such a non-profit entity does not yet exist, and the millions who suffer from needle phobia seem, so far, to have little interest in such an endeavor.
I would like to change that, but that dream is a long way off. It is very important that any donations you make to the Needle Phobia Page reflect its value to you, the reader. I want my future decisions about to what extent I should continue my work against needle phobia to reflect the value to you of what I have done so far. It is not necessary to have a PayPal account to donate. To use a credit card when you get to the PayPal web site, just click on continue near the bottom of the PayPal page instead of logging in. James Hamilton's article, Needle Phobia: This reprint request must be made in a separate email to me at:.
Your email should request the reprint and state the exact mailing address where the reprint should be sent. Also, state the date of your contribution to this web site and the amount. Only one reprint per person, please. For readers outside of the United States, please read the following:. Additional postage is required to send reprints to United Kingdom, Australia and Canada. For readers in these countries, the minimum donation to receive a reprint is as follows:. When I run out of these official reprints, I do not intend to purchase any more.
They flip coins over who gets to go first. I should probably mention that we did a delayed and spaced out vaccination schedule. They get one shot at a time. They have given their full and enthusiastic consent. Autism is a totally different beast from just pure needle phobia. Do you have some autism resources?
They just make me sick. I understand the reason for them and have looked into alternativesbut i wont do it. Ive already postponed it for 2 years. A few months ago I had surgery to have a tumour removed, it went successful but now they have to test me very often to check up and want me to start taking needles at home 6 days a week. You can still feel the needle but it at least takes away most of the pain. I really appreciate it when you suggested the use of anti-anxiety medication on the person if we can see that they really are terrified of shots.
My brother has been afraid of needles since he was younger, and he never really got over it. Now that his job requires him to have interventional injections, I can see that his struggle is real. Maybe it will be good to suggest using anti-anxiety meds on him to calm him down. That idea just might work, to be honest, because my daughter can be distracted easily. I will speak with the clinician about her fear as she will have her flu shot next month.
Seattle Children's complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion creed , sex, gender identity or expression, sexual orientation, national origin ancestry , age, disability, or any other status protected by applicable federal, state or local law. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.
Magnet Recognized Nursing Program. Most parents with asthmatic children get flu shots yearly, early in the season. If you make and break that promise, trust is broken. Fear of needles is real. Validate your child when they state they are terrified. And then talk directly with the clinician about ways to support your child during the shots. Consider using an anti-anxiety medication something like Ativan, Valium, or Xanax when true needle phobia is present.
Consider using a numbing cream something like EMLA or vapocoolant spray to numb the skin prior to the vaccination. Consider deep breathing and other behavioral modifications including distraction at the time of injections to support your child. Consider seeing a behavioral health clinician as well. Studies and reports from my patients confirm it works brilliantly! July 20, at 1: October 27, at 8: July 20, at 9: July 24, at 5: October 24, at 9: February 5, at 1: Karen Crisalli Winter says: April 27, at October 3, at 7: July 27, at 9: July 10, at 6: September 3, at 7: