Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England.

BACKGROUND: Injection site infections among injecting drug users (IDUs) have been associated with serious morbidity and health service costs in North America. This study explores the frequency, factors and costs associated with injection site infections among IDUs in England. METHODS: Unlinked-anonymous survey during 2003/05 recruiting IDUs from community settings at seven locations across England. Self-reported injecting practice, symptoms of injection site infections (abscess or open wound) and health service utilisation data were collected using a questionnaire, participants also provided dried blood spot samples (tested for markers blood borne virus infections). Cost estimates were obtained by combining questionnaire data with information from national databases and the scientific literature. RESULTS: 36% of the 1,058 participants reported an injection site infection in the last year. Those reporting an injection site infection were more likely to be female and aged over 24, and to have: injected into legs, groin, and hands in last year; injected on 14 or more days during the last four weeks; cleaned needles/syringes for reuse; injected crack-cocaine; antibodies to hepatitis C; and previously received prescribed substitute drug. Two-thirds of those with an injection site infection reported seeking medical advice; half attended an emergency department and three-quarters of these reported hospital admission. Simple conservative estimates of associated healthcare costs range from pound 15.5 million per year to as high as pound 30 million; though if less conservative unit costs assumptions are made the total may be much higher (pound 47 million). The vast majority of these costs are due to hospital admissions and the uncertainty is due to little data on length of hospital stays. CONCLUSION: Symptoms of injection site infections are common among IDUs in England. The potential costs to the health service are substantial, but these costs need more accurate determination. Better-targeted interventions to support safer injection need to be developed and evaluated. The validity of self-reported symptoms, and the relationship between symptoms, infection severity, and health seeking behaviour require further research

Harm reduction among injecting drug users - evidence of effectiveness

This chapter synthesises and evaluates the available direct evidence relating to the impact of needle and syringe programmes (NSPs), opioid substitution treatment (OST), drug consumption rooms (DCRs), and peer naloxone distribution (PND) on HIV/hepatitis C (HCV) incidence/prevalence, injecting risk behaviour and overdose-related mortality. To achieve this, we conducted a review of reviews; a systematic and explicit method used to identify, select and critically appraise relevant findings from secondary level research (systematic reviews and/or meta-analyses) into an evidence briefing. In the absence of high-quality reviews, appraisal of the evidence was supplemented with a targeted review of the primary literature. We find that there is sufficient review-level evidence that OST reduces HIV transmission, while the evidence in support of NSPs reducing HIV transmission is more tentative, and for DCRs currently insufficient. There is tentative evidence that OST has limited effectiveness in reducing HCV transmission, and insufficient evidence to support or discount NSPs or DCRs' ability to reduce HCV transmission. There is sufficient review-level evidence that NSPs, OST and DCRs reduce self-reported injecting risk behaviour. There is sufficient review evidence that OST reduces risk of overdose mortality, but insufficient evidence to support or discount the effect of DCRs or PND on overdose deaths at the community level. Our review shows evidence in support of a variety of harm reduction interventions but highlights an uneven presence of high-quality review evidence. Future evaluation of harm reduction programmes should prioritise methodologically robust study designs

The choreography of the classroom: performance and embodiment in teaching

The body is central to all human interaction and is literally the instrument through which teachers communicate. The topic of embodiment has increasingly been addressed in the literature on Education and more broadly in the Social Sciences, however there are few accounts of what embodiment looks like in actual teaching; how it enhances communication of the curriculum, and shapes teachers’ relationships with the students. Using a multiple case study methodology, I examine the embodied teaching styles of two university professors to investigate the intrinsic complexities that arise in the practice of teaching. The literature on corporality often characterizes the body as a text to be "read" by scholars prioritizing a static approach to embodiment focused on issues of identity. Little has been offered on the physical dimension of embodiment focusing on the sensory experience of being a moving feeling human being. This study offers new perspectives on the performance of teaching through a choreographic framework that emphasizes the role of the body in performance, as well as adding new insights into the relationship between the design of a course, and how it is orchestrated in the live performance space of the classroom. Three distinctive yet interrelated themes emerged during this study: the embodied, the structural, and the relational. Each theme contributed to create the implicit curriculum of the class, and offers distinctive insights into the tacit dimension of communication that is both ubiquitous and difficult to articulate. The first set of findings relates to the ways teachers embody and communicate the curriculum, examining the common gestures, movement patterns, pacing, and energetic dynamics used to animate their lectures. To honor embodied ways of interacting and communicating, it was essential to develop a method that could analyze movement data. Skills and techniques to study movement from dance were used to explore the everyday movements of teachers and bring to the forefront the specific ways each communicated concepts with the body. Attention to the embodied highlighted the qualitative and sensory dimension of teaching. For instance, I was attuned to how each teacher reacted to the attitude and energy level of the students and adjusted their tone of voice, pace of the class, or entire lesson plan to engage students in learning. The second set of findings investigates the relationship between the structural design of a course and how teachers orchestrate the planned curriculum within the classroom. A choreographic frame broadens the scope of the study to examine the aesthetic dimensions of the classroom. For instance, how each teacher chooses to vary the pace, energy, and focus of the class to communicate concepts and ideas to the students, as well interweave multiple streams of information through their embodied communication, the content of the lectures, power point and visual illustrations, etc. In this chapter, the role of the teacher as a designer of the educational experience is explored in relation to how they make the curriculum come alive in the performative space of the classroom. The third set of findings draws explores the relational aspects of teaching and examines how each teacher conceptualized and enacted caring in the classroom. This section investigate the ever-present challenge teachers face; how to build a relationship of trust and understanding with students, while concurrently offering challenges that will encourage them to grow and flourish. This study address issues integral to teacher education including the relationship between the planned curriculum and the way it is implemented in the classroom, as well as the relational dynamic developed between teachers and students. The performing arts provide a framework for understanding artistry in teaching highlighting the convergence of the performative, the creative design and orchestration of curriculum, and the relational aspects of teaching to make vivid the rich sensory world of the tacit dimension and how it creates the ambience for learning

Insertion and Presence of Fine-wire Intramuscular Electrodes to the Lumbar Paraspinal Muscles Do Not Affect Muscle Performance and Activation during Highexertion Spinal Extension Activities

Background Low back pain (LBP) is commonly associated with paraspinal muscle dysfunctions. A method to study deep lumbar paraspinal (i.e. multifidus) muscle function and neuromuscular activation pattern is intramuscular electromyography (EMG). Previous studies have shown that the procedure does not significantly impact muscle function during activities involving low-level muscle contractions. However, it is currently unknown how muscular function and activation are affected during high-exertion contractions. Objective To examine the effects of insertion and presence of fine-wire EMG electrodes in the lumbar multifidus on muscle strength, endurance, and activation profiles during high-exertion spinal extension muscle contractions. Design Single-blinded, repeated measures intervention trial. Setting University clinical research laboratory Participants Twenty individuals between the ages of 18-40 free of recent and current back pain. Methods Muscle performance was assessed during 3 conditions (with [WI] and without [WO] presence of intramuscular electrodes, and insertion followed by removal [IO]). Isometric spinal extension strength was assessed with a motorized dynamometer. Muscle endurance was assessed using the Sorensen test with neuromuscular activation profiles analyzed during the endurance test. Main Outcome Measurements Spinal extensor muscle strength, endurance, and activation. Results Our data showed no significant difference in isometric strength (p=.20) between the 3 conditions. A significant difference in muscle endurance was found (p=.03). Post-hoc analysis showed that the muscle endurance in the IO condition was significantly higher than the WO condition (161.3±58.3 vs. 142.1±48.2 sec, p=.04), likely due to a learning effect. All 3 conditions elicited minimal pain (range 0-4/10) and comparable muscle activation profiles. Conclusion Our findings suggested the sonographically guided insertion and presence of fine-wire intramuscular EMG electrodes in the lumbar multifidus muscles had no significant impact on spinal extension muscle function. This study provides evidence that implementing intramuscular EMG does not affect muscle performance during high-exertion contractions in individuals with no current back pain. Level of Evidence I

Crack-heroin speedball injection and its implications for vein care: Qualitative study

Background We report on an exploratory qualitative study investigating drug injectors’ narratives of vein damage and groin (femoral vein) injection associated with the injection of crack-heroin speedball. Methods We undertook 44 in-depth qualitative interviews among injectors of crack-heroin speedball in Bristol and London, England, in 2006. Findings Data suggests an emerging culture of crack-based speedball injection. Injectors’ narratives link speedball injection with shifts towards groin injection articulated as an acceptable risk and not merely as a last resort in the face of increased vein deterioration associated with speedball. Accounts of vein damage linked to speedball emphasise ‘missed hits’ related to the local anaesthetic action of crack, the excess use of citric in the preparation of speedball injections, and ‘flushing’ when making a hit. We find that groin injection persists despite an awareness of health risks and medical complications. Conclusions We emphasise an urgent need for reviewing harm reduction in relation to vein care in the context of shifts to crack-based speedball injection, and the use of the femoral vein, among UK injectors. There is an additional need for interventions to promote safer groin and speedball injecting as well as to prevent transitions toward groin and crack injection

The Edinburgh Addiction Cohort: recruitment and follow-up of a primary care based sample of injection drug users and non drug-injecting controls.

BACKGROUND: Injection drug use is an important public health problem. Epidemiological understanding of this problem is incomplete as longitudinal studies in the general population are difficult to undertake. In particular little is known about early life risk factors for later drug injection or about the life course of injection once established including the influence of medical and social interventions. METHODS: Individuals thought to be drug injectors were identified through a single primary medical care facility in Edinburgh between 1980 and 2006 and flagged with the General Registry Office. From October 2005 - October 2007, these cases were traced and invited to undergo interview assessment covering early life experience, substance use, health and social histories. Age and sex matched controls for confirmed cases (alive and dead) were later recruited through the same health facility. Controls for living cases completed the same structured interview schedule. Data were also collected on cases and controls through linkage to routine primary care records, death registrations, hospital contact statistics and police and prison records. All interviews were conducted with the knowledge and permission of the current GP. RESULTS: The initial cohort size was 814. At start of follow up 227 had died. Of the remaining 587: 20 had no contact details and 5 had embarked from the UK; 40 declined participation; 38 did not respond to invitations; 14 were excluded by their GP on health or social grounds and 22 had their contact details withheld by administrative authorities. 448 were interviewed of whom 16 denied injection and were excluded. Of 191 dead cases with medical records 4 were excluded as their records contained no evidence of injection. 5 interviewed cases died before follow up was concluded though these individuals were counted as "live" cases. 1 control per case (dead and alive) was recruited. Linkage to Scottish Morbidity Records data (available from 1981 onwards) on general acute inpatient and day cases, mental health inpatient and day cases and cancer was provided by Information Services, NHS Scotland, for all cases interviewed and all dead cases. The Scottish Prison Service provided records for 198 (46%) of cases interviewed, 48 cases not interviewed and 34 (18%) of dead cases. For a sub-sample of 100 interviewees a search of the Lothian and Borders police database was made for official criminal records and 94 had criminal records. Data linkage for controls is ongoing. CONCLUSIONS: Injecting drug users recruited from a community setting can be successfully followed-up through interviews and record linkage. Information from injecting cases is being analysed in terms of injecting patterns and possible influences on these. Comparisons between cases and controls will allow identification of possibly modifiable early life risk factors for drug injection and will also clarify the burden of disease associated with injection and the influence on this of different health and social interventions.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment

Objectives To examine survival and long term cessation of injecting in a cohort of drug users and to assess the influence of opiate substitution treatment on these outcomes

Injecting drug use and unstable housing: Scope for structural interventions in harm reduction

Evidence links unstable housing, and especially homelessness, with elevated health harm among drug users, including riskier drug injecting practices. We undertook 45 in-depth qualitative interviews with injecting drug users (IDUs) in Bristol and London in 2006. IDUs were recruited through drug user networks and drug agencies. Temporary accommodation and hostels for the homeless may provide a ‘safe haven’ from street-based drug use and public injecting environments, and are characterised as a retreat from the ‘chaos’ of the street. But hostels may also constitute ‘risk environments’ in facilitating drug using and risk networks, transitions to new patterns of use, including increased frequency of injecting. For some, homelessness was positioned as ‘safer’ than temporary housing with regards to managing drug use. Stable housing emerges as a key structural factor in creating enabling environments for health. We emphasise that temporary accommodation hostels have potential for harm-reduction interventions, but may also be associated with the production of risk related to drug use and injecting

Estimating the number of people who inject drugs in Australia

Abstract Background Injecting drug use is associated with considerable morbidity and mortality. Estimates of the size of the population of people who inject drugs are critical to inform service planning and estimate disease burden due to injecting drug use. We aimed to estimate the size of the population of people who inject drugs in Australia. Methods We applied a multiplier method which used benchmark data (number of people in opioid substitution therapy (OST) on a snapshot day in 2014) and multiplied it by a factor derived from the prevalence of current OST among people who inject drugs participating in the Australian Needle and Syringe Program Survey in 2014. Estimates of the total population of people who inject drugs were calculated in each state and territory and summed to produce a national estimate. We used the sex and age group distribution seen in datasets relating to people who inject drugs to derive sex- and age-stratified estimates, and calculated prevalence per 1000 population. Results Between 68,000 and 118,000 people aged 15–64 years inject drugs in Australia. The population prevalence of injecting drug use was 6.0 (lower and upper uncertainty intervals of 4.3 and 7.6) per 1000 people aged 15–64 years. Injecting drug use was more common among men than women, and most common among those aged 35–44 years. Comparison of expected drug-related deaths based on these estimates to actual deaths suggest that these figures may be underestimates. Conclusions These are the first indirect prevalence estimates of injecting drug use in Australia in over a decade. This work has identified that there are limited data available to inform estimates of this population. These estimates can be used as a basis for further work estimating injecting drug use in Australia