Examining HIV pre-exposure prophylaxis (PrEP) acceptability among rural people who inject drugs: predictors of PrEP interest among syringe service program clients.

Rural communities in the US have increasing HIV burden tied to injection drug use, yet engagement in pre-exposure prophylaxis (PrEP) care has been low among people who inject drugs (PWID). Syringe service programs (SSPs) are widely implemented in Kentucky's Appalachian region, presenting an important opportunity to scale PrEP services. This paper examines PrEP awareness, interest and preferences among PWID attending community-based SSPs in Appalachia. Eighty participants were enrolled from two SSP locations. Eligibility included: ≥ 18 years old, current injection drug use and SSP use, and an indication for PrEP as defined by CDC guidelines. Participants completed a structured baseline interview. Predictors of PrEP awareness, interest and formulation preferences were examined. 38.8% reported baseline awareness of PrEP, 50% expressed high interest in PrEP, and 48.1%reported a preference for injectable PrEP. Significant bivariate predictors of PrEP interest included: current worry about health, higher perceived HIV risk, higher community HIV stigma, and higher enacted substance use stigma in the past year; in the adjusted model, enacted substance use stigma remained significant. Findings demonstrate substantial interest in PrEP among rural PWID. Intrapersonal and social determinant factors were associated with PrEP interest, which suggests the importance of multi-level intervention targets to increase PrEP uptake.

High prevalence of hepatitis C virus among criminals in rehabilitation facilities in Japan.

OBJECTIVE: There is a high prevalence of hepatitis C virus (HCV) carriers in prison in several developed countries, but the situation in Japan has not been well reported. This study aimed to determine the state of HCV infection among criminals in Japan. METHODS: We enrolled 533 criminals in rehabilitation facilities (354 men and 179 women) who underwent a medical check-up from April 2014 to March 2022. Their records of blood tests, medical history, and drug injection use were retrospectively analyzed. RESULTS: The HCV-antibody positive rate was 11.1 % (59/533), with rates of 8.2 % (29/354) in men and 16.8 % (30/179 in women. Approximately half of the HCV-infected residents had a history of drug injection, and this rate did not vary by age or by sex. Although an opportunity to treat HCV infection with medical assistance from government was provided to all residents who were positive for HCV RNA, 26.5 % of them abandoned the treatment. CONCLUSION: In spite of the generous economical support to treat HCV infection by the government and the free access system in Japan, eliminating HCV in criminals appears to be difficult. The reason for this problem might be the criminals' negligent attitude to life.

Self-Reported Illicitly Manufactured Fentanyl Use and Associated Health and Substance Use Risks in the United States, 2022.

OBJECTIVE: Illicitly manufactured fentanyl (IMF) has emerged as a catalyst of the recent drug epidemic in the United States. To devise more targeted and effective prevention and treatment strategies, it is crucial to understand the demographics of the population who consumes IMF and their health and associated substance use risks. Therefore, this study explores the sociodemographic characteristics, health diagnoses, and drug injection practices of individuals reporting IMF use. METHODS: Data were derived from the 2022 National Survey on Drug Use Health, based on a nationally representative sample of non-institutionalized individuals aged 12 and older in the United States. Focusing on 306 adults who reported ever using IMF, we examined their sociodemographic characteristics, health diagnoses, and substance-related behaviors in comparison to adults with a drug use disorder who did not report IMF use, using logistic regression analyses. RESULTS: The majority of U.S. adults reporting IMF use were aged 35-64, male, non-Hispanic White, with a high school education or lower, never married, and had an annual household income below $40,000. Compared to adults with a drug use disorder who did not report IMF use, they were more likely to report heart conditions (AOR = 2.67, 95% CI = 1.29-5.54) and Hepatitis B or C (AOR = 8.35, 95% CI = 4.05-17.02). Nearly half of this group had an opioid use disorder (OUD) in the past year, and 65.7% (95% CI = 56.7-74.8) reported a history of injecting drugs. CONCLUSIONS: To effectively curb the current drug epidemic, incorporating effective treatment for OUD and harm reduction strategies is crucial.

Reducing the harms of xylazine: clinical approaches, research deficits, and public health context.

OBJECTIVES: Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine's harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine's public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine's current and emerging contexts. METHODS: To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors. RESULTS: We describe xylazine's major harm domains-acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine's epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context. CONCLUSIONS: Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.

Trends and distinct profiles of persons who inject drugs in the United States, 2015-2019.

Drug injection represents a major health problem in the US, with severe health consequences including the transmission of blood-borne infections. An examination of the most recent trends in drug injection is warranted by the fast-evolving drug epidemic and recent policy changes such as the federal funding ban on needle exchange programs. This research examines current drug injection trends, patterns, and socioeconomic and behavioral profiles of people who inject drugs (PWID). Data were derived from the 2002 to 2019 National Survey on Drug Use and Health (NSDUH). After examining the annual prevalence of drug injection since 2002, a latent class analysis was conducted to identify drug injection and other substance misuse patterns among PWID using the latest (2015-2019) NSDUH datasets. Associations between class membership and behavioral health comorbidities and treatment receipt were also assessed. The drug injection prevalence among US adults aged 18-64 increased from 0.21% in 2002/2004 to 0.36% in 2017/2019. Three distinctive groups were identified: the heroin injection group (45.2%), the methamphetamine injection group (28.0%), and the multi-drug injection group (26.8%). The methamphetamine injection group reported greater risks of experiencing serious psychological distress, suicidality, and limited substance use treatment. Special attention is needed for those who primarily injected methamphetamine. Programs to promote harm reduction and increase access to addiction treatment need to be expanded in at-risk communities while accounting for their distinct socioeconomic and drug use/misuse profiles.

Sexualized drug injection among men who have sex with men in Madrid and Barcelona as the first episode of drug injecting.

BACKGROUND: We estimate the prevalence of drug injection, the variables associated with having ever injected and the proportion of ever injectors whose first drug injection was for having sex; we describe the first drug injection episode, analyze the drugs most frequently injected and estimate the prevalence of risky injecting behaviors. METHODS: The participants were 3387 MSM without a previous HIV diagnosis attending four HIV/STI diagnosis services in Madrid and Barcelona. Lifetime prevalence and prevalence ratios (PRs) by different factors were calculated using Poisson regression models with robust variance. We compared the characteristics of first drug injection episode, lifetime injection and risky injecting behaviors of those whose first injection was for sex (FIS) with those whose was not (non-FIS). RESULTS: Lifetime prevalence of injection was 2.1% (CI 1.7-2.7). In the multivariate analysis, it was strongly associated with having been penetrated by more than five men in the last 12 months (aPR = 10.4; CI 2.5-43.4) and having met most of their partners at private parties (aPR = 7.5; CI 4.5-12.3), and less strongly with other factors. Of those who had ever injected drugs, 81.9% injected for sex the first time they injected drugs (FIS). At first injection, FIS participants had a mean age of 31 years, 62.7% used mephedrone and 32.2% methamphetamine on that occasion. Of this FIS group 39.0% had ever shared drugs or equipment and 82.6% had always shared for sex. Some 30.8% of non-FIS reported having also injected drugs for sex later on. CONCLUSIONS: Only two out of a hundred had ever injected, most to have sex and with frequent drug or injecting equipment sharing. Injecting for sex is the most common first episode of drug injection and is the most efficient risky behavior for the transmission of HIV, hepatitis B or C and other blood-borne infections. MSM participating in private parties should be considered a priority group for prevention policies.

Interaction and conflict between outreach workers and research officers in implementing collaborative action research in the field of harm reduction: a qualitative study.

BACKGROUND: The effectiveness of collaborative approaches in health interventions is underlined in the literature. Given the serious challenges to adequately managing the HCV epidemic in people who inject drugs (PWID), and the need to improve existing harm reduction (HR) interventions in this population, it seems important to investigate how collaboration between stakeholders is ensured in action research interventions. The present study aimed to explore interactions between outreach workers and research officers collaborating in the implementation of an action research project for PWID entitled OUTSIDER. METHODS: Using three focus groups, we studied the views of 24 outreach workers involved in the implementation and evaluation of a harm reduction educational intervention to help PWID inject more safely in off-site settings. RESULTS: The analysis of participants' discourses highlighted the mixed perceptions they had about OUTSIDER. Several limitations to collaboration emerged. Epistemological (theoretical vs. practical knowledge), methodological (science vs. intervention), axiological (standardised vs. adapted approach), and material (mobilised vs. available resources) issues all placed a burden on the outreach worker-research officer relationship. Outreach workers' acceptance of the project's intervention dimension but rejection of its scientific dimension highlights a lack of contractualisation between the stakeholders involved, and a more general problematisation of the role of outreach workers in implementing action research in HR. How collaboration was perceived and practised by outreach workers participating in OUTSIDER can be considered a reflection of the current challenges to implementing action research in HR. CONCLUSION: This study of the interaction between the research and implementation dimensions of an action research project explored the tensions between different intervention stakeholders that must work together. Equitable participation and integration of the expertise, practices, and knowledge of all stakeholders involved is essential for successful action research. Given current HCV epidemiological challenges, new forms of cooperation are needed when developing healthcare services and when strengthening collaborative approaches.

How effective is periarticular multimodal drug injection in open elbow arthrolysis? A prospective double-blind randomized controlled trial.

BACKGROUND: Evidence on the efficacy and safety of periarticular multimodal drug injection (PMDI) in open elbow arthrolysis (OEA) is limited. This study aimed to investigate differences in postoperative pain, blood loss, and range of motion (ROM) between PMDI vs. no injection among patients undergoing OEA, and the presence of PMDI-related complications. METHODS: This prospective, double-blind randomized controlled trial included 59 patients who underwent OEA. Patients randomly received PMDI (ropivacaine, epinephrine, ketoprofen) before wound closure or no injection. The primary outcomes were elbow pain over the first postoperative week at rest and during motion, measured using the visual analog scale (VAS). VAS scores were compared to attain the 20-mm threshold values for a minimum clinically important difference. Parecoxib consumption on OEA night and postoperative days (PODs) 1-3 and total consumption during the first postoperative week were recorded. Blood loss was recorded every 24 hours until POD 3. ROM during rehabilitation was measured daily from day 1 to day 7 after surgery, as well as at 3-month follow-up. Medication-related side effects were recorded prospectively. RESULTS: The mean VAS score showed clinically important differences between PMDI and control groups at rest on OEA night (mean difference [MD], 25 mm; P < .001) and first 3 PODs with motion (POD 1: MD, 28 mm, P < .001; POD 2: MD, 21 mm, P < .001; POD 3: MD, 21 mm, P < .001) but not in other postoperative assessments. Parecoxib consumption was lower in the PMDI group on OEA night and PODs 1-3. Total parecoxib consumption during the first postoperative week was lower in the PMDI group vs. the control group (MD, 148 mg; P < .001). Blood drainage was less in the PMDI group vs. the control group on POD 1 (MD, 38 mL; P = .016) but not on POD 2 (P = .950), POD 3 (P = .259), or total (P = .184). The PMDI group exhibited significantly better ROM during the first 4 PODs than the control group, whereas there was no difference at 3-month follow-up. No medication-related side effects were noted in the PMDI group. CONCLUSION: PMDI effectively relieves pain and reduces analgesic consumption for OEA patients, without an apparent increase in risks.

Drug injection and associated factors among the elderly living with HIV/AIDS in Tehran, Iran.

Background: Injection of drugs is one of the most serious health problems among Iranian living with HIV/AIDS. The injection of drugs, accounting for the transmission of more than two-thirds of HIV infections. HIV remains a major concern around the world and is expected to be the third leading cause of mortality worldwide. Thus, the aim of this study was to explore the predictors of injection drug use in the elderly patients living with HIV/AIDS. Methods: This was a cross-sectional study executed in Tehran City, Iran, in 2018. A total of 160 individuals aged 60 years and older with HIV from different counseling centers were selected by convenience sampling. Data were collected using questionnaires including a positive state of mind, coping, social support, and a checklist of demographical variables. Bivariate analysis and multiple logistic regression using SPSS software version 21.0 were employed to determine factors associated with drug injection. The statistical tests were performed with a significance level of 5% (p≥0.05). Results: The study participants' mean(SD) age was 65.6(±6.6) years. In total, 33 people (20.6%) of the samples reported injection drug use. The frequency of injection drug use was greater among men (AOR: 2.28, 95% CI 2.2-22.8; p=0.010), those reporting a monthly income of ≥30000000 Rials (AOR: 31.56, 95% CI 2.95-338; p=0.004), subjects with past experience of drug use (AOR: 7.11, 95% CI 2.18-23.2; p=0.001), those with ≥2 years past from their HIV diagnosis (AOR: 4.04, 95% CI 1.12-14.58; p=0.033), and those living with more than two people in one residential place (Household size AOR: 5.9, 95% CI 1.64-21.24; p=0.007). Conclusion: It seems that the design and implementation of harm reduction programs among the elderly with HIV/AIDS who inject drugs are essential and should be considered as an agenda of policymakers and health professionals.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs.

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

Hepatitis A virus survival on drug paraphernalia.

The ongoing hepatitis A outbreaks in multiple states in the United States have concerned public health authorities since March 2017. The outbreaks have spread throughout 30 states and include primarily persons who use drugs, including persons who inject drugs (PWID) and persons experiencing homelessness. Contaminated drug injection paraphernalia and sharing of these items could potentially aid in transmission of hepatitis A virus (HAV) among these populations. We examined HAV survival on drug paraphernalia frequently shared among PWIDs. The effect of low pH on HAV survival using citric acid, which is frequently used by PWIDs during dose preparation, was investigated. We compared the plaque assay results with those concurrently obtained by qRT-PCR to establish whether HAV RNA levels could be used as surrogates for plaque assay results. HAV suspended in minimal essential media at room temperature infected FRhK4 cells for more than 17 weeks. HAV remained viable in syringes/needles for up to 10 weeks depending on the gauge of the needles and the syringe dead volumes, and on cookers, tourniquets and cotton balls/filter surfaces for up to 4 weeks. HAV retained its infectivity for more than 10 weeks at pH as low as 2. In conclusion, our findings show that HAV survives and remains infective in or on injection drug use equipment for 1 to 10 weeks depending on the type of paraphernalia examined and environmental conditions. These findings suggest that contaminated drug paraphernalia can potentially facilitate the transmission of HAV within populations who share these items.

Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study.

OBJECTIVE: The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran. METHODS: We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds. RESULTS: HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus. CONCLUSIONS: HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.

Comparative effectiveness of various treatment strategies for trigger finger by pairwise meta-analysis.

OBJECTIVE: To compare the efficacy of various strategies in the treatment of trigger finger. DATA SOURCES: A systematic literature search for randomized controlled trials to compare treatments for trigger finger was conducted through three online databases, Pubmed, Embase and Cochrane Library, from their inception dates to 22 May 2020. METHODS: Relative risk (RR) with 95% confidence interval (CI) was used to evaluate the effect sizes in success rate for included articles. RESULTS: Sixteen articles (n = 1185) were included in our meta-analysis. The results showed that the efficacy of steroid injection was significantly better than the placebo group at short-term follow-ups (RR = 19.00, 95% CI = 1.17-309.77 for one-week; RR = 3.70, 95% CI = 3.70, 95% CI = 1.61-8.53 for one-month), and then became non-significant at four months (RR = 3.21, 95% CI = 0.88-11.79). There was no significant difference in success rate between steroid injection and nonsteroidal anti-inflammatory drug injection, and between open surgery and percutaneous release at all the follow-ups. Only surgical treatment had significantly better efficacy in success rate than steroid injection at all follow-ups (RR = 0.48, 95% CI = 0.34-0.66 for one-month; RR = 0.87, 95% CI = 0.80-0.96 for three-month; RR = 0.58, 95% CI = 0.48-0.68 for six-month; RR = 0.38, 95% CI = 0.20-0.72 for 12-month). CONCLUSION: There were no differences in efficacy between steroid injection and shockwave or nonsteroidal anti-inflammatory drug injection. The surgical treatments had the best efficacy among these treatments.

Prevalence of HIV/Hepatitis C Virus Co-Infection and Injection Risk Correlations in People Who Inject Drugs in Colombia: A Cross-Sectional Study Using Respondent Driven Sampling.

Background: In Colombia, an exponential growth of people who inject drugs (PWID) has been reported over the past decades. The main burden of disease in PWID is attributed to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and their co-infection is associated with poor prognosis, high morbidity and treatment related implications. Nevertheless, the prevalence of HIV/HCV co-infection in Colombian PWIDs is unknown. Objective: To determine the prevalence, demographic characteristics, and injecting behaviors of HIV/HCV co-infected PWID in Colombia. Methods: This was a cross-sectional study of 1,123 PWID recruited by respondent driven sampling in five Colombian cities between January and June of 2014. Each participant completed a quantitative survey, and blood samples for HIV and HCV antibody testing were obtained. A multinomial logistic regression was used for statistical analysis. Results: Average participant age was 26.3 ± 6.5 years, and the majority was male (86%). HIV or HCV mono-infection prevalence was 27.6%, while co-infection was 3.3%. Compared with PWID with mono-infection, co-infected PWID exhibited higher odds of: injecting ≥4 times daily (OR: 3.5; CI: 1.7-7.2; p < .001), cleaning needles and syringes with water (OR 3.2; CI: 1.6-6.3; p < .001), passing drug mix between syringes (OR: 2.7; CI: 1.3-5.3; p = .04), injecting on illegal indoor shooting galleries (OR: 2.4; CI: 1.0-5.3, p = .02), and getting injected by someone who charges for injecting (OR 2.3; CI: 1.0-5.2; p = .04). Conclusion: Prevalence of HIV/HCV co-infection among PWID in Colombia is lower than that reported in other countries. However, addressing the identified demographic characteristics and injection risk behaviors of co-infected PWID is essential for the implementation of broadly available harm reduction interventions as well as routine HIV/HCV testing and treatment strategies aiming to control the spread of both viruses and their associated morbidity and mortality.

Factors Associated with Gabapentin Misuse among People Who Inject Drugs in Appalachian Kentucky.

AIMS: Gabapentin is misused to potentiate the euphoric effects of opioids, self-treat physical pain, and moderate opioid withdrawal symptoms. Because examinations of gabapentin misuse among people who inject drugs (PWID) are scant, the aim of this study is to identify factors associated with gabapentin misuse among this population. Methods: Data are drawn from a study examining the uptake of syringe service programs (SSPs) in Appalachian Kentucky. The sample includes 324 PWID who were age 18 and over and reported past month drug injection. Logistic regression models were constructed to examine recent (past 90 days) gabapentin misuse. Results: Participants are female (50.0%); Hispanic (2.2%), Black (1.5%), white (90.7%), and other race/ethnicity (4.6%). Mean age is 37. Participants reporting gabapentin misuse had higher odds of reporting (mis)use of marijuana, cocaine, methamphetamine, prescription opioids, benzodiazepines, prescription stimulants, fentanyl, and buprenorphine (p < .042); severe substance use disorder (p < .000); and recent physical pain (p < .003). In multivariable models, findings related to misuse of prescription opioids and buprenorphine; severe substance use disorder; and recent physical pain or discomfort, remained significant (p < .042). Conclusions: This is one of the first studies to examine gabapentin misuse among PWID. It is possible that individuals reporting recent gabapentin misuse are attempting to self-treat physical pain when healthcare is limited. Gabapentin may also be misused to achieve desired central nervous system effects and to potentiate opioid highs. Syringe service programs can educate PWID about the potential dangers of polydrug use involving gabapentin and to connect PWID with needed healthcare services.

HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy.

PURPOSE OF REVIEW: Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing. RECENT FINDINGS: Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.

Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial.

BACKGROUND: Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points. METHODS: This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject's knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery. RESULTS: Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed. CONCLUSIONS: Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA. TRIAL REGISTRATION: The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No. TCTR20170617001 on 16 June 2017.

Assessment rate of true dorsogluteal intramuscular drug injection using ultrasonography.

OBJECTIVE: Medications are generally administered by either the enteric or parenteral route. With parenteral administration, intramuscular (IM) is the preferred approach because it increases the bioavailability of the drug, acts more quickly than the enteric route. The aim of this study was to determine the rate of true dorsogluteal intramuscular drug injection and to determine the causes for application failures in practice by ultrasonography (US). METHODS: The study was conducted from May 1 to May 30, 2017 in Giresun University Education and Research Hospital, Giresun, Turkey. We examined 60 patients who were administered dorsogluteal IM injection with a 38.1mm length needle. After the injection, localization of medications (whether intramuscular or subcutaneous adipose tissue [SAT]) was evaluated by Ultrasound. RESULTS: Female/male ratio of the patients was 27/33, with a mean age of 39.78±2.16 years. Obese/normal weight ratio was 20/40. The mean dorsogluteal area SAT thickness of obese and normal weight patients were 32.34±2.17 mm and 20.85±1.20 mm, respectively. In 23 of the patients, IM injected drug was observed in the SAT, while it was observed in the IM area in 37 patients. Medication was observed in IM area in 37 of 50 patients who dorsogluteal region SAT thickness was appropriate (SAT thickness lower than 33.1mm) for IM injection while it was seen in SAT area in 13 patients. CONCLUSIONS: SAT thickness values are important if IM drug injection is to be administered correctly. Unsuccessful IM injections may be seen even in patients with appropriate SAT thicknesses.

A comparative study comparing area of extension of posterior knee capsule via posteromedial injection: a cadaveric study.

BACKGROUND: Periarticular multimodal drug injection (PMDI) has gained popularity as common postoperative pain protocols in knee arthroplasty. PMDI sites can vary, but posterior capsule (PC) is a common injection site because of its abundance of pain nociceptors. PURPOSE: To prove the hypothesis whether posteromedial drug injection alone is sufficient to provide enough effect covering the PC in order to reduce risks of neurovascular injury. Secondary outcomes are to find proper volume of injection and safe zone for PMDI injection. METHODS: Ten fresh cadaveric knees were allocated into two equal groups, which differed in volume of dye injection: 25 ml and 50 ml. Dyes were injected into posteromedial capsule compartment, and the limbs were stored in a freezer for 2 weeks. Then the posterior compartment was carefully dissected to examine spreading of the dye solution. RESULTS: No dye staining was seen superficially beneath subcutaneous tissue of the knees. In deeper layer, the dye mostly occupied medially along the fascia covering semimembranosus muscles. However, dispersion was limited distally by intermuscular septa and popliteal vessels. The 50-ml injection group provided wider extension in the superficial layer, but not in the deep layer. CONCLUSION: The intermuscular septa and the fascia of popliteal vessels were shown to be the boundary between posteromedial and posterolateral compartments of the knee. Separate PMDI for both compartments is necessary to occupy the entire PC. We suggest that 1.5 cm lateral to lateral border of PCL insertion, just above popliteus tendon, is the safe zone for injecting PMDI into the posterolateral capsule.