Purchase data: a proxy for safety status.

This study demonstrated the use of purchase data to determine the incidence of sharps injuries in a major tertiary referral hospital in Australia. The incidence rates of injuries per 100,000 items purchased were 2.65 and 12.60 for syringe needles and scalpel blades, respectively. These figures were lower than those reported previously using this method. The incidence rate for injuries with suture needles, which had not been reported previously, was 31.89/100,000 items purchased. Incidence data calculated in this manner may be used in conjunction with purchase cost estimates to inform policy and practices on institutional staff safety measures.

Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis.

OBJECTIVE: From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision. DESIGN: Costing study and longitudinal cohort study. SETTING: Tijuana, Mexico. PARTICIPANTS: Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study. PRIMARY OUTCOME MEASURES: Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal. RESULTS: During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02). CONCLUSIONS: Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.

Feasibility of needle and syringe programs in Tajikistan distributing low dead space needles.

BACKGROUND: In 2012, the World Health Organization recommended that needle and syringe programs offer their clients low dead space insulin syringes with permanently attached needles. However, in many countries, these syringes are not acceptable to a majority of people who inject drugs. This study assessed the feasibility of working with needle and syringe programs to implement the WHO recommendation using low dead space detachable needles. The study also assessed the acceptability of the needles. METHODS: Two needle and syringe programs in Tajikistan-one in Kulob and one in Khudjand-received 25,000 low dead space detachable needles each. The programs distributed low dead space detachable needles and a marketing flyer that emphasized the relative advantages of the needles. Each program also enrolled 100 participants, and each participant completed a baseline interview and a 2-month follow-up interview. RESULTS: At follow-up, 100% of participants reported trying the low dead space detachable needles, and 96% reported that they liked using the needles. Both needle and syringe programs distributed all their needles within the first 60 days of the project indicating use of the needles, even among clients who did not participate in the study. CONCLUSIONS: This project demonstrates that it is feasible for needle and syringe programs to offer and promote low dead space needles to their clients. The findings indicate that low dead space needles are acceptable to needle and syringe program clients in these Tajikistan cities. To reduce HIV and hepatitis C virus transmission, needle and syringe programs should offer low dead space needles, low dead space insulin syringes in addition to standard needles, and syringes to their clients.

Epinephrine, auto-injectors, and anaphylaxis: Challenges of dose, depth, and device.

OBJECTIVE: This review was undertaken to review epinephrine dosing, site and route of administration, focusing on special populations (patients weighing less than 15 kg, and obese patients); and to discuss storage and delivery of epinephrine in prehospital and hospital settings. DATA SOURCES: Review of published literature. STUDY SELECTION: Relevance. RESULTS: The recommended 0.01-mg/kg (maximum 0.3-0.5 mg) epinephrine dose in anaphylaxis is based on limited pharmacokinetic data in healthy volunteers. No pharmacokinetic or pharmacodynamics studies involving patients in anaphylaxis have been published. When epinephrine auto-injectors (EAIs) are used in infants, the dose increasingly exceeds the recommended dose as weight decreases, although the clinical significance of this is unclear. Limited data indicate that the intramuscular route and lateral thigh site are superior. Ultrasound studies suggest that 0.15 EAI needles may be too long for many patients weighing less than 15 kg, and 0.3 mg EAI needles may be too short for obese patients weighing more than 30 kg. A newly available 0.1 mg EAI has a lower dose and shorter needle better suited to patients weighing 7.5 to 15 kg. In some medical settings, vials and syringes may provide a safe, efficient alternative with substantial cost savings over EAIs. CONCLUSION: EAIs should be available in the community with doses and needle depths that meet the needs of all patients. More research on epinephrine pharmacodynamics are needed in children and adults in anaphylaxis, to better delineate what optimal doses should be. Optimizing epinephrine dose and delivery has the potential to improve anaphylaxis outcomes and prevent adverse events.

How does the use of multiple needles/syringes per injecting episode impact on the measurement of individual level needle and syringe program coverage?

BACKGROUND: Recent work by McCormack et al. (2016) showed that the inclusion of syringe stockpiling improves the measurement of individual-level syringe coverage. We explored whether including the use of a new parameter, multiple sterile syringes per injecting episode, further improves coverage measures. METHODS: Data comes from 838 people who inject drugs, interviewed as part of the 2015 Illicit Drug Reporting System. Along with syringe coverage questions, the survey recorded the number of sterile syringes used on average per injecting episode. We constructed three measures of coverage: one adapted from Bluthenthal et al. (2007), the McCormack et al. measure, and a new coverage measure that included use of multiple syringes. Predictors of multiple syringe use and insufficient coverage (<100% of injecting episodes using a sterile syringe) using the new measure, were tested in logistic regression and the ability of the measures to discriminate key risk behaviours was compared using ROC curve analysis. RESULTS: 134 (16%) participants reported needing multiple syringes per injecting episode. Women showed significantly increased odds of multiple syringe use, as did those reporting injection related injuries/diseases and injecting of opioid substitution drugs or pharmaceutical opioids. Levels of insufficient coverage across the three measures were substantial (20%-28%). ROC curve analysis suggested that our new measure was no better at discriminating injecting risk behaviours than the existing measures. CONCLUSION: Based on our findings, there appears to be little need for adding a multiple syringe use parameter to existing coverage formulae. Hence, we recommend that multiple syringe use is not included in the measurement of individual-level syringe coverage.

Differential access to syringe exchange and other prevention activities among people who inject drugs in rural and urban areas of Puerto Rico.

BACKGROUND: Injection drug use and its associated blood-borne infections has become a rapidly increasing problem in rural areas of the US recently. Syringe exchange programs have been shown to be effective for reducing transmission of blood borne infections, however access to these prevention efforts may be limited in rural areas. METHODS: This paper utilizes two separate community samples of people who inject drugs (PWID) in Puerto Rico to achieve the following research objectives: (1) compare rural and urban access to syringe exchange programs, free sterile syringes and other HIV/HCV prevention activities, and (2) examine whether utilization of prevention activities is associated with lower injection risk behaviors. Two samples were recruited with RDS (n=315 rural sample; n=512 urban sample) and included adults aged 18 years and older who have injected drugs within the past month. RESULTS: 78.5% of the urban sample utilized a syringe exchange program in the past year, compared to 58.4% of the rural sample (p<.001). 71.4% of the urban sample received free sterile needles, compared to 58.4% of the rural sample (p<.001). 66% of the urban sample received free works compared to 59% of the rural sample (p=.034). 29% of urban PWID had a conversation with an outreach worker about HIV prevention compared to 18% of the rural sample (p<0.001). Receiving free needles significantly increases the frequency of using a sterile needle to inject (p<.001). CONCLUSION: Urban PWID were significantly more likely to have utilized syringe exchange programs, received free sterile needles, received free works, and to have talked about HIV prevention with an outreach worker during the past year than PWID residing in rural areas. Individuals who accessed these prevention activities were significantly less likely to exhibit risky injection behavior. Policy implications call for increasing access to prevention services in rural areas to reduce disease transmission.

Rural people who inject drugs: A cross-sectional survey addressing the dimensions of access to secondary needle and syringe program outlets.

OBJECTIVE: To better understand issues related to access to injecting equipment for people who inject drugs (PWID) in a rural area of New South Wales (NSW), Australia. DESIGN: Cross-sectional face-to-face survey using convenience and snowball sampling. SETTING: Six regional and rural population centres in Northern NSW, within the Hunter New England Local Health District. PARTICIPANTS: The sample included 190 PWID who had accessed a needle and syringe program outlet within 4 weeks of the survey. MAIN OUTCOME MEASURES: Data include demographic information, preferred location for accessing injecting equipment, reasons for that preference, whether they obtained enough equipment, travelling distance to an NSP and self-reported hepatitis C virus status. RESULTS: Sixty percent self-identified as Aboriginal people. The median age of respondents was 32 years and 60% were men. A significantly larger proportion (P < 0.05) of the Aboriginal respondents were women (27% versus 11.6%) and younger (37.6 versus 12.7%) compared to non-Aboriginal respondents. Most preferred to access injecting equipment at a community health facility (62.6%), as opposed to other secondary outlets, where they gained enough equipment (67.4%). Just over 80% said they were tested for HCV in the past year, with about 37% told they had tested positive. CONCLUSIONS: There are complex dimensions affecting how rural PWID access secondary NSP outlets. Although access is similarly limited as other rural health services because of the nature of injecting drug use and sensitivities existing in rural communities, there is potential for application of unique access models, such as, promoting secondary distribution networks.

Impacto del calibre de las agujas en la calidad de la hemodiálisis / Impact of the needle gauge in the quality of hemodialysis

Introducción: El flujo de sangre es uno de los factores íntimamente relacionado con la eficacia de la diálisis. Flujos altos de sangre se asocia a mejor calidad de diálisis y para ello, se recomienda el uso de agujas de gran calibre. Objetivo: Analizar el efecto del calibre de las agujas utilizadas en la punción de las fístulas arteriovenosas, así como, examinar su impacto en la percepción del dolor y en el tiempo de coagulación tras su retirada al finalizar la sesión. Material y método: Se ha llevado a cabo un estudio transversal. Se han recogido datos utilizando para la punción de la fístula arteriovenosa agujas de calibre 15G y 16G. Las variables recogidas han sido velocidad de bomba, flujo efectivo, Kt/V, presión venosa, duración de la sesión, tensión arterial sistólica, tensión arterial diastólica, recirculación, grado de dolor y tiempo de coagulación. Además, se han recogido las variables edad, sexo y localización del acceso vascular. Resultados: En 52 fístulas analizadas se ha encontrado diferencias estadísticamente significativas en el uso de los distintos calibres de aguja en las variables flujo de sangre efectivo, presión venosa y duración de la sesión. Discusión: Los resultados de nuestro estudio nos permiten recomendar el uso de aguja 15G ya que nos permitirán utilizar altos flujos de sangre sin generar morbilidad para el paciente, permitiendo alcanzar la dosis de diálisis recomendada en menos tiempo de tratamiento (AU)

Introduction: Blood flow is a factor closely related to the dialysis efficacy. High blood flows are associated with better quality of dialysis and therefore the use of large needle gauge is recommended. Objective: Analyze the effect of gauge needles in the puncture of arteriovenous fistulas and examine its impact on the perception of pain and bleeding time after his retirement at the end of the session. Methods: A cross-sectional study was conducted. Data were collected using 15G and 16G needles to puncture the arteriovenous fistula. The variables are pump speed, effective flow, Kt/V, venous pressure, session length, systolic blood pressure, diastolic blood pressure, recirculation, degree of pain and clotting time. In addition, we have collected the variables age, sex and location of the vascular access. Results: In 52 analyzed fistulas found statistically significant differences in the use of different needle gauges in the variables effective blood flow, venous pressure and duration of the session. Discussion: The results of our study allow us to recommend the use of 15G needles because they will allow us to use high blood flows without generating morbidity for the patient, allowing reaching the recommended dose of dialysis treatment in less time (AU)

Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis.

BACKGROUND: Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission. METHODS: Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis. RESULTS: There were 12 studies comprising at least 12 000 person-years of follow-up. Exposure to NSP was associated with a reduction in HIV transmission: pooled effect size 0·66 [95% confidence interval (CI) 0·43, 1·01] across all studies, and 0·42 (95% CI 0·22, 0·81) across six higher quality studies (according to the Newcastle-Ottawa tool). CONCLUSIONS: There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Dense arrays of micro-needles for recording and electrical stimulation of neural activity in acute brain slices.

OBJECTIVE: This paper describes the design, microfabrication, electrical characterization and biological evaluation of a high-density micro-needle array. The array records from and electrically stimulates individual neurons simultaneously in acute slices of brain tissue. APPROACH: Acute slices, arguably the closest in-vitro model of the brain, have a damaged surface layer. Since electrophysiological recording methods rely heavily on electrode-cell proximity, this layer significantly attenuates the signal amplitude making the use of traditional planar electrodes unsuitable. To penetrate into the tissue, bypassing the tissue surface, and to record and stimulate neural activity in the healthy interior volume of the slice, an array of 61 micro-needles was fabricated. MAIN RESULTS: This device is shown to record extracellular action potentials from individual neurons in acute cortical slices with a signal to noise ratio of up to ∼15:1. Electrical stimulation of individual neurons is achieved with stimulation thresholds of 1.1-2.9 µA. SIGNIFICANCE: The novelty of this system is the combination of close needle spacing (60 µm), needle heights of up to 250 µm and small (5-10 µm diameter) electrodes allowing the recording of single unit activity. The array is coupled to a custom-designed readout system forming a powerful electrophysiological tool that permits two-way electrode-cell communication with populations of neurons in acute brain slices.

Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews.

AIMS: To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes. METHODS: Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements. RESULTS: Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes. CONCLUSIONS: The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-à-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Staff perceptions of syringe dispensing machines in Australia: a pilot study.

BACKGROUND/AIMS: Syringe dispensing machines were introduced into needle syringe programs (NSPs) two decades ago. The few published studies on dispensing machines have focused on feedback of machine users and service providers' feedback has rarely been reported. This study obtained the feedback of health staff of NSPs, other sectors of Drug Misuse Treatment Services and of other health services adjoining dispensing machines on the role and effectiveness of dispensing machines. METHODS: Between August and November 2006, questionnaires were anonymously completed by NSP and drug misuser treatment staff in an Area Health Service in Sydney, as well as by the staff of two nondrug-related health services located adjacent to needle syringe dispensing machines. The questionnaire was available in either paper or Internet based forms. RESULTS: Almost 80% of 94 participants rated dispensing machines as either moderately successful or successful in reducing sharing of needles and syringes. Staff considered that introduction of these machines to NSPs had improved services for injecting drug users without increasing unsafe disposal of used equipment, community drug use, or vandalism. However 78% of respondents felt that dispensing machines either reduce or may reduce IDUs' opportunity for staff contact and hence opportunity for engagement or education. The study limitations were noted. CONCLUSION: Syringe dispensing machines are perceived to be a successful and appropriate outlet of NSPs that complement other outlets. Lack of staff-user contact was seen as their main disadvantage.

[Conditions of dental extractions in areas health centers of Senegal]. / Etude des conditions de l'extraction dentaire dans les centres de santé des districts du Sénégal.

Dental extraction is a surgical act frequently carried out in the African dental structures. It requires the rigorous respect of the conditions of asepsis and antisepsis. Equipments and anaesthetic and avulsional products must be also sufficient. Our study undertaken among 46 dental services in areas health centers of Senegal aimed to determine the conditions under which dental extractions are carried out. The principle results of our study showed that 93% of dental practitioners wore sterilized gloves. 49% of the dentist's care activity consisted in dental extractions. 50% of the practitioners re-use anaesthetic needles, 2% re-use anaesthetic carpules. We noticed that the dental structures were facing a deficit of materials and products of extraction. Face to the outbreak of serious illnesses as infections of HIV and Hepatitis B, the practitioner and his team must be sensitized and trained to struggle against the transmissible infections and to carry out the dental extraction only if the conditions of asepsis and antisepsis are joined together. A pleading towards the medical authorities must be done to support the services in equipments and periodic renewals of the materials and products of extractions.

Infant intraosseous infusion.

Neonatal health care providers are fortunate that the umbilical cord generally provides easy intravenous (IV) access for newborn patients. Outside of the immediate newborn period, however, it may be impossible to obtain peripheral or umbilical IV access in critically ill newborns. Intraosseous (IO) infusion is not widely used in the neonatal population, but is a viable option when IV access cannot be established quickly. This article examines IO infusion devices and placement sites and addresses assessment and care of the infant receiving IO fluids and medications.

Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study.

INTRODUCTION AND AIMS: The study examines risk behaviours of the users of syringe dispensing machines (SDMs) and evaluates the usefulness of these machines in providing injecting drug users (IDUs) with sterile injecting equipment. DESIGN AND METHODS: Self-administered questionnaires were used among users of SDMs in an Area Health Service of Sydney. RESULTS: The majority of the 167 participants reported being happy with the quality of the SDM services. Problems identified with machines were that they were often broken or jammed (32.8% respondents), not in the right place (21.9%) or require money (16.7%). Just over half (50.9%) of the IDUs use SDMs only from 5 p.m. to 9 a.m., the time when almost all other outlets for accessing sterile injecting equipment remain closed. Relatively young IDUs (age < or = 30 years) were more likely to prefer SDMs over staffed needle syringe programmes (NSPs) compared with older users (age > 30) and to identify stigma (a desire to hide their identity or not liking the way people treat them at staffed NSPs or chemists) as a main reason for using these machines. Primary users of SDMs do not differ from primary users of NSP/chemists in terms of sharing of needles. Those users who had shared in the last month were nearly four times as likely to have never used condoms in sexual encounters over that period (95% confidence interval: 1.2 - 14.5). DISCUSSION AND CONCLUSION: SDMs appear to complement other outlets of NSPs. Providing free-of-cost equipment from SDMs should be considered carefully, as needing money to buy equipment was a reason given for sharing of needles by 35% of those who shared.

Harm reduction product distribution in British Columbia.

OBJECTIVES: The British Columbia Centre for Disease Control (BCCDC) tracks the distribution of all harm reduction products subsidized by the BC government, including needles and syringes, sterile water vials, alcohol swabs, condoms, and lubricant. This study measures the distribution of harm reduction products in BC, identifies regional variation in distribution, and estimates the supply/demand ratio for needle and syringe units. METHODS: Using three years of administrative data (2004-2006) from the BCCDC, the quantity of harm reduction products distributed was calculated by Health Service Delivery Area (HSDA). Regional hepatitis C virus (HCV) case report rates were calculated to reflect potential variation in IDU populations at the HSDA-level and the number of needle and syringe units distributed per reported case of HCV was calculated and ranked by HSDA. To compare the demand for sterile injecting equipment to the distribution, the number of illicit drug injections per year was approximated using established estimates of IDU populations in BC and Vancouver. RESULTS: Marked regional variation exists in the rates of harm reduction product distribution per 100,000 residents aged 15-64. The average number of needle and syringe units distributed annually in BC from 2004-2006 was 5,382,933. The estimated number of injections per year in BC is 24,951,144, suggesting the province distributed 21.5% of the units required to cover all illicit drug injections in the province. DISCUSSION: Harm reduction product distribution is not equitable between BC HSDAs. The current level of distribution of sterile injecting equipment is inadequate to provide a clean needle for every injection.