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SIGNpost 00730

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *

Post00730 Perilous needles + Abstracts Catch Up 29 January 2014

CONTENTS
0. Moderators Note: Updated
1. Article: Perilous infection-control practices with needles, syringes,
and vials: vigorous monitoring is crucial
2. Abstract: Use of Hub Cutters and the Volume of Sharp Waste and
Occurrence of Needle-Stick Injuries during 2011 Mass Immunization
Campaigns against Yellow Fever in Ghana: A Cohort Study.
3. Abstract: Unsafe injection practices in Hodeidah governorate, Yemen
4. Peritonitis Attributed to Contamination of Multidose Vials of Culture
Medium Supplement
5. Abstract: The structure of a professional viral hepatitis morbidity in
medical staff in the Primorsky Krai
6. Abstract: Outbreak of hepatitis C among patients admitted to the
Department of Gynecology, Obstetrics, and Oncology
7. Abstract: Health care workers causing large nosocomial outbreaks: a
systematic review
8. Abstract: Prevalence of hepatitis B and hepatitis C infection in Libya:
results from a national population based survey
9. Abstract: Intravitreal injections: a review of the evidence for best
practice
10. Abstract: A Patient with Fatal Necrotizing Fasciitis following the Use
of Intra-Articular Sodium Hyaluronate Injections: A Case Report
11. Abstract: Intra-articular hyaluronic acid injection versus oral non-
steroidal anti-inflammatory drug for the treatment of knee
osteoarthritis: a multi-center, randomized, open-label, non-
inferiority trial
12. Abstract: Improving waste segregation while reducing costs in a
tertiary-care hospital in a lower-middle-income country in Central
America
13. Abstract: Treatment as prevention among injecting drug users;
extrapolating from the Amsterdam cohort study
14. Abstract: Overdose prevention in injecting opioid users: The role of
substance abuse treatment and training programs
15. Abstract: Significant differences in clinical outcomes between HIV-
hepatitis C virus coinfected individuals with and without injection
drug use history
16. Abstract: Beginning the journey of hand hygiene compliance monitoring
at a 2,100-bed tertiary hospital in Vietnam
17. Abstract: Prospective randomized clinical trial: single and weekly
viscosupplementation
18. Abstract: Functional outcome of collagenase injections compared with
fasciectomy in treatment of Dupuytren’s contracture
19. Abstract: Maladministrations in nuclear medicine: revelations from the
Australian Radiation Incident Register
20. Abstract: Evaluation and treatment of accidental autoinjection of
epinephrine
21. No Abstract: In regard to the paper: Developments in the necessity and
coverage of the syringe exchange program in Spanish prisons,
1992-2009. Estimation after correction
22. No Abstract: Mitigating the risk of HIV infection with opioid
substitution treatment
23. No Abstract: Knowledge, attitude and practice towards infection
control among healthcare professionals

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________________________________*_________________________________

0. Moderators Note
__________________________________________________________________

10 February Update: Apologies! After recovering from the worst cold in
decades I discovered that this edition of SIGNpost had not gone out to
SIGN subscribers due to an transmission error. Am posting today – out of
order so that readers will have the complete set.
__________________________________________________________________
This catch-up edition of SIGNpost contains all abstracts of articles
on injection safety and related infection control published and added to
the database over the end of 2013 and early 2014.

Please note that item 2, contains the abstract and link to the full free
text of an article by our late colleague Yves Chartier and his colleagues
in the field.

” Use of Hub Cutters and the Volume of Sharp Waste and
Occurrence of Needle-Stick Injuries during 2011 Mass Immunization
Campaigns against Yellow Fever in Ghana: A Cohort Study. ”

very best for 2014,
allan
__________________________________________________________________
________________________________*_________________________________

1. Article: Perilous infection-control practices with needles, syringes,
and vials: vigorous monitoring is crucial
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875254/

P T. 2013 Nov;38(11):649-66.

Perilous infection-control practices with needles, syringes, and vials:
vigorous monitoring is crucial.

Grissinger M.

Avoiding dangerous lapses in infection-control practices.

Problem: A survey of 5,446 health care professionals in 2010 revealed an
alarming lapse in basic infection-control practices associated with the
use of syringes, needles, multiple-dose vials, single-use vials, and flush
solutions.1 Survey respondents were primarily registered nurses (89.5%)
who worked in hospitals.

Although most nurses and other practitioners appeared to follow infection-
control practices consistent with current recommendations of the Centers
for Disease Control and Prevention (CDC),2 some survey respondents clearly
placed patients at risk for transmission of blood-borne diseases,
according to information sent to the Institute for Safe Medication
Practices (ISMP) from the survey’s sponsor, Premier Healthcare Alliance.1
The survey revealed some disturbing results:

Nearly 1% of respondents acknowledged that they sometimes or always reused
a syringe for more than one patient after changing only the needle.
Six percent of respondents admitted to sometimes or always using single-
dose or single-use vials for multiple patients.

Fifteen percent of respondents reported using the same syringe to re-enter
a multiple-dose vial numerous times. Of this group, about 7% reported
saving these multiple-dose vials for use with other patients.

Nine percent of respondents sometimes or always used a common bag or
bottle of IV solution as a source of flushes and drug diluents for
multiple patients.

Each of these unsafe practices has been associated with disease
transmission and is explicitly prohibited by the CDC.2

The comments provided by respondents demonstrated a general lack of
awareness, as well as many misconceptions, regarding safe infection-
control practices. For example, one frequent comment was that the reuse of
a single-dose vial depended on the size of the vial; this reflects the
erroneous notion that a large volume of medication alone makes it suitable
for multiple patients.

Respondents also thought that changing the needle on a used syringe was
sufficient protection against disease transmission if aspiration of blood
did not occur and if there was no visible blood in the syringe. Although
most respondents called reuse of a syringe “appalling,” some respondents
appeared unaware that disease could be transmitted when they reused a
syringe after the needle was changed. Pathogenic contaminants not visible
to the eye can enter the syringe after injection, particularly while the
needle is still attached to the syringe.

The ISMP has published numerous articles about this problem, including a
special alert that appeared in the February 2009 edition of the ISMP
newsletter after a hospital placed more than 2,100 insulin-dependent
diabetic patients at risk for acquiring blood-borne diseases when staff
used insulin pen devices for multiple diabetic patients after changing
only the pen’s needle between patients.3–5

The danger of reusing a syringe to withdraw a medication or solution from
a multiple-dose container might not seem obvious; rather, health care
practitioners probably undertake this unsafe practice without much thought
when multiple doses of the medication (e.g., lidocaine) or solution (e.g.,
saline) are required during a single procedure. If syringes are
deliberately reused after changing the needle, clinicians might
erroneously believe that the spread of any residual pathogens will be
halted by the bacteriostatic or preservative agents in the multiple-dose
vials. Although common preservatives used in multiple-dose vials may be
bacteriostatic, they do not destroy all bacteria and do not have antiviral
or antifungal activity. Furthermore, even if the preservative effectively
stops bacteria from reproducing, there is a 2-hour window during which
contaminating organisms may remain viable in a multiple-dose vial before
the preservative fully exerts its effect.6

Respondents’ comments regarding the use of a bag or bottle of IV solution
(e.g., saline) as a common source of flushes or drug diluents for multiple
patients suggest some awareness of the risk of contamination.
Nevertheless, other respondents erroneously suggested that this practice
was safe because they discarded the solution after 24 hours. However,
limiting use to a 24-hour period does not prevent disease transmission if
the bag becomes contaminated. Further, use of a contaminated solution for
large groups of patients can result in widespread disease transmission.

It has been more than 15 years since the ISMP first wrote about the risks
associated with these practices.7 In fact, a hepatitis B outbreak related
to the reuse of syringes to access multiple-dose heparin vials was the
topic of a feature article during the inaugural year of the ISMP
Medication Safety Alert! in 1996.7 Since then, the topic has been covered
in dozens of feature articles in ISMP publications.

According to the CDC, since the year 2000, there have been more than 50
outbreaks of blood-borne transmission of hepatitis B, hepatitis C, and HIV
that required more than 125,000 potentially exposed patients to be
notified and more than 600 who became infected to be identified.1 The
study authors suggested that these outbreaks represented only a portion of
the incidence of blood-borne pathogen transmission caused by unsafe
injection practices. Many outbreaks and sporadic transmissions of
hepatitis B and C, for example, go unrecognized, because patients who are
infected may be asymptomatic initially or may have mild, nonspecific
symptoms for years.

Safe Practice Recommendations: Given the lapses in infection-control
practices and misconceptions regarding unsafe injection procedures
described in this survey, academic settings, licensing bodies, and health
care providers must enhance their ongoing surveillance of proper technique
and devote resources to ensure staff knowledge and skills associated with
even the most basic concepts of infection control and injection safety.

The One and Only Campaign (one needle, one syringe, only one time), led by
the CDC and the Safe Injection Practices Coalition, offers free posters,
educational brochures for health care practitioners and patients, and a
13-minute video on the topic.8

All staff members should understand that any form of syringe or needle
reuse is dangerous and should be avoided. The current CDC guidelines
recommend that syringes and needles be used only once.2 Single-dose or
single-use vials should be used clinically only for one dose for one
patient and then discarded after initial entry into the vial. If multiple-
dose vials are used, both the needle and syringe used to access the vial
must be sterile, and strict attention must be paid to aseptic technique.
The ISMP and the CDC also recommend limiting the use of multiple-dose
vials of medication to individual patients, whenever possible, as an extra
barrier of protection against unrecognized reuse of a syringe or other
means of unintended vial contamination.2 It is safest to use prefilled
syringes or single-dose vials, if possible, to reduce the risk of
contamination.

Certainly, it can make sense to use multiple-dose vials in some settings:
for a single patient; during aseptic pharmacy compounding; and with the
use of expensive medications, which should be prepared and dispensed from
the pharmacy in unit doses.

The relatively inexpensive drugs and solutions that often require multiple
entries into the vial (e.g., sodium chloride injection 0.9%,
bacteriostatic water, lido-caine) should not be saved for use by other
patients. These drugs should be provided in single-use containers that are
discarded after the first use. Also, bags or bottles of IV solutions
should not be used as a communal supply for multiple patients unless these
items are used during aseptic pharmacy compounding with a fluid-dispensing
system.

REFERENCES

1. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices
among clinicians in United States health care settings. Am J Infect
Control. 2010;38:789–798. Available at:
https://www.premierinc.com/quality-safety/tools-
services/safety/topics/safe_injection_practices/index.jsp. Accessed
October 16, 2013. [PubMed]

2. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings. Atlanta: Centers for Disease Control and Prevention;
2007. pp. 1–225. Available at:
www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf. Accessed October 16,
2013. [PubMed]

3. Institute for Safe Medication Practices (ISMP) Reuse of insulin pen for
multiple patients risks transmission of bloodborne disease. ISMP
Medication Safety Alert! 2009 Feb 15;

4. Office of Inspector General Inappropriate use of insulin pens.
Available at: www.va.gov/oig/pubs/vaoig-13-01320-200.pdf. Accessed
September 24, 2013.

5. FDA Information for Healthcare Professionals: Risk of Transmission of
Blood-borne Pathogens from Shared Use of Insulin Pens. Mar 19, 2009.
updated August 15, 2013. Available at:
www.fda.gov/Drugs/DrugSafety/Postmarket-
DrugSafetyInformationforPatientsand-
Providers/DrugSafetyInformationforHeathcareProfessionals/ucm133352.htm.
Accessed September 24, 2013.

6. Wilson JP, et al. Updating your multiple-dose vial policy: The
background. Hosp Pharm. 1998;33:427–432.

7. Institute for Safe Medication Practices (ISMP) Hepatitis B outbreak
related to multiple dose heparin vials should serve as a wakeup call. ISMP
Medication Safety Alert! 1996;1(14):1.

8. The One and Only Campaign Available at:
www.oneandonlycampaign.org/content/audio-video. Accessed September 20,
2013.

Articles from Pharmacy and Therapeutics are provided here courtesy of
MediMedia, USA
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Use of Hub Cutters and the Volume of Sharp Waste and
Occurrence of Needle-Stick Injuries during 2011 Mass Immunization
Campaigns against Yellow Fever in Ghana: A Cohort Study.
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24463796

Int J Occup Environ Med. 2014 Jan;5(1):9-17.

Use of Hub Cutters and the Volume of Sharp Waste and Occurrence of Needle-
Stick Injuries during 2011 Mass Immunization Campaigns against Yellow
Fever in Ghana: A Cohort Study.

Agbenu E, Chartier Y, Eleeza J, Antwi-Agyei KO, Diamenu S, Ronveaux O,
Perea W.

BACKGROUND: Current WHO best infection control practices for injections do
not address the use of hub cutters due to insufficient evidence on safety
and efficacy.

OBJECTIVE: To assess the impact of the use of hub cutters on 1) the
frequency of needle-stick injuries (NSIs) and other blood exposures among
workers and 2) the volume of sharps waste in a mass vaccination campaign
setting.

METHODS: During yellow fever vaccination in Ghana, we conducted a cohort
study on the use of hub cutters. We compared two groups—one group using
hub cutters and a control group—for the occurrences of NSIs and the
volume of sharp waste produced.

RESULTS: In the control arm, vaccinators used 284 482 syringes in 825
vaccination sessions. In the group using hub cutter, vaccinators used 397
079 syringes in 1599 sessions. Among vaccinators, the rate of NSI was not
significantly (p=0.14) different between the hub cutter users (0.15/10 000
syringes) and the control group (0.04/10 000). Factors such as workload,
lack of organization and pressure seemed to have influence the occurrence
of NSIs. With all the limitations of the work, the volume of sharp waste
per 10 000 syringes was 0.24 m(3) in the hub cutter users and 0.41 m(3) in
the control group—a reduction of 41.2%. Vaccinators found hub cutters
easy to use and safe. Use of hub cutter was not associated with increased
duration of work.

CONCLUSION: The use of hub cutters did not increase the risk of NSIs. More
training is needed to facilitate its implementation in mass campaign
setting.

Free full text
http://www.theijoem.com/ijoem/index.php/ijoem/article/view/303/433
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Unsafe injection practices in Hodeidah governorate, Yemen
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23806699

J Infect Public Health. 2013 Aug;6(4):252-60.

Unsafe injection practices in Hodeidah governorate, Yemen.

Abkar MA, Wahdan IM, Sherif AA, Raja’a YA.

BACKGROUND: Unsafe injection practices are a major public health problem
and can lead to the transmission of bloodborne pathogens, including
hepatitis B virus (HBV), hepatitis C virus (HCV) and human
immunodeficiency virus (HIV).

METHODS: The present study was conducted to determine the nature and
magnitude of unsafe injection practices in healthcare facilities in
Hodeidah governorate, Yemen. The study was conducted in two hospitals and
a representative sample of the governorate’s health centers. A total of
1600 injections were observed in these facilities.

RESULTS: This study revealed several unsafe practices, particularly the
recapping of needles after use, which occurred in 61.1% and 36.8% of the
observations in the hospitals and the health centers, respectively.

CONCLUSION: This study showed that most healthcare workers (HCWs) followed
the proper injection protocols but performed some procedures that exposed
themselves and the community to the risk of needlestick injuries (NSIs)
and bloodborne infections.

Copyright © 2013 King Saud Bin Abdulaziz University for Health Sciences.
Published by Elsevier Ltd. All rights reserved.
__________________________________________________________________
________________________________*_________________________________

4. Peritonitis Attributed to Contamination of Multidose Vials of Culture
Medium Supplement
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24442075

Infect Control Hosp Epidemiol. 2014 Feb;35(2):139-43.

Pseudo-Outbreak of Klebsiella oxytoca Spontaneous Bacterial Peritonitis
Attributed to Contamination of Multidose Vials of Culture Medium
Supplement.

Perez F, Deshpande A, Kundrapu S, Hujer AM, Bonomo RA, Donskey CJ.

Objective. To determine the source of a cluster of Klebsiella oxytoca
isolates cultured from peritoneal fluid of 3 patients with cirrhosis on a
single day. Design. Outbreak investigation and before-after study.

Setting. A Veterans Affairs medical center.

Methods. Epidemiologic investigation, analysis of antimicrobial
susceptibility testing results and molecular typing of K. oxytoca isolates
with repetitive sequence-based polymerase chain reaction (rep-PCR), review
of microbiology laboratory procedures for processing peritoneal fluid
cultures, and comparison of peritoneal fluid contamination rates 18 months
before and after modification of laboratory procedures for culturing
peritoneal fluid.

Results. Each of the peritoneal fluid samples that grew K. oxytoca was
inoculated into blood culture bottles by different clinicians at different
hospital locations. None of the patients had clinical findings suggestive
of peritonitis or elevated polymorphonuclear cell counts in peritoneal
fluid (range, 3-25 cells/µL). Molecular typing with rep-PCR demonstrated
that the K. oxytoca isolates were genetically related (greater than 95%
similarity). Laboratory procedures included the routine addition of a
culture medium supplement of yeast extract and dextrose from a multidose
vial into blood culture bottles with peritoneal fluid. After discontinuing
use of the culture medium supplement, there was a marked reduction in the
number of peritoneal fluid cultures deemed as contaminants (14.3% vs 0.9%;
[Formula: see text]).

Conclusion. A pseudo-outbreak of K. oxytoca peritonitis and high rates of
contamination of peritoneal fluid were attributable to contamination of a
multidose culture medium supplement. This article highlights the
importance of discouraging the use of multidose vials in all clinical
settings.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: The structure of a professional viral hepatitis morbidity in
medical staff in the Primorsky Krai
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24340581

Gig Sanit. 2013 May-Jun;(3):51-3.

[The structure of a professional viral hepatitis morbidity in medical
staff in the Primorsky Krai].

[Article in Russian]

Bektasova MB, Kaptsov VA, Sheparev AA.

The study of cases with occupational parenteral viral hepatitis “B”, “C”
in the medical personnel of health institutions was conducted on 238
epidemiological maps infectious focus (Form 357/u)for the period
1996-2011.

At the same time 1,000 employees of health facilities were surveyed with
the aim to determine the awareness of health professionals workers about
the risk of parenteral viral hepatitis “B”, “C”, ways of the transmission
and danger level of infection, the level of knowledge on prevention of
occupational infection, prevention of infringement of the measures in the
work of medical staff that increase the risk of transmission of viral
hepatitis. The age of the subjects ranged from 20 to 73 years. The average
age was 43,9 +/- 1,8 years. 83.1% out of them were females, 16.9% – males

There is an urgent need to study the occupational occurrence of parenteral
viral hepatitis in health staff in the dynamics for the development and
timely adoption measures for prevention
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Outbreak of hepatitis C among patients admitted to the
Department of Gynecology, Obstetrics, and Oncology
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24388479

Am J Infect Control. 2014 Jan;42(1):e7-e10.

Outbreak of hepatitis C among patients admitted to the Department of
Gynecology, Obstetrics, and Oncology.

Rorat M1, Jurek T2, Szleszkowski L2, Gladysz A2.

BACKGROUND: In Poland, nosocomial infections account for 32% of all
patients’ claims against public hospitals, with hepatitis B virus and
hepatitis C virus (HCV) being the most common causes. We present a major
nosocomial outbreak of the HCV infection in the Department of Gynecology,
Obstetrics, and Oncology and the results of detailed sanitary and
epidemiologic research.

METHODS: A retrospective analysis of medicolegal opinions issued at the
request of the civil court regarding the suspicion of HCV nosocomial
infections was conducted.

RESULTS: The detailed medical data analysis proved 26 patients aged 19 to
72 years with recent HCV hepatitis hospitalized on the same gynecology
ward. Twenty women were operated on for neoplasm. The State Sanitary
Inspection’s investigation revealed a number of malpractices: incorrect
sterilization procedures, insufficient hygiene habits of health care
workers, poor condition of premises, and equipment being in poor
condition. Numerous cases of staff breaking basic sanitary rules and
hygiene standards and a lack of crucial procedures were discovered. The
high number of women infected and the multiple errors recognized led to
closure of the ward.

CONCLUSION: Outbreaks of HCV hepatitis may be the result of ineffective
infection control systems and remains a significant public health problem.
Asymptomatic HCV nosocomial infections might go unnoticed or concealed and
underreported. Auditing medical centers and health care workers for
compliance with sanitary and epidemiologic requirements is an essential
need.

Copyright © 2014 Association for Professionals in Infection Control and
Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

KEYWORDS:
Adverse event, Equipment contamination, Infection control, Safety
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Health care workers causing large nosocomial outbreaks: a
systematic review
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23432927

BMC Infect Dis. 2013 Feb 22;13:98.

Health care workers causing large nosocomial outbreaks: a systematic
review.

Danzmann L, Gastmeier P, Schwab F, Vonberg RP.

BACKGROUNDS: Staff in the hospital itself may be the source of a
nosocomial outbreak (NO). But the role of undetected carriers as an
outbreak source is yet unknown.

METHODS: A systematic review was conducted to evaluate outbreaks caused by
health care workers (HCW). The Worldwide Outbreak Database and PubMed
served as primary sources of data. Articles in English, German or French
were included. Other reviews were excluded. There were no restrictions
with respect to the date of publication.Data on setting, pathogens, route
of transmission, and characteristics of the HCW was retrieved. Data from
large outbreaks were compared to smaller outbreaks.

RESULTS: 152 outbreaks were included, mainly from surgery, neonatology,
and gynecology departments. Most frequent corresponding infections were
surgical site infections, infection by hepatitis B virus, and septicemia.
Hepatitis B virus (27 NO), S. aureus (49 NO) and S. pyogenes (19 NO) were
the predominant pathogens involved. 59 outbreaks (41.5%) derived from
physicians and 56 outbreaks (39.4%) derived from nurses. Transmission
mainly occurred via direct contact. Surgical and pediatric departments
were significantly associated with smaller outbreaks, and gynecology with
larger outbreaks. Awareness of carrier status significantly decreased the
risk of causing large outbreaks.

CONCLUSIONS: As NO caused by HCW represent a rare event, screening of
personnel should not be performed regularly. However, if certain species
of microorganisms are involved, the possibility of a carrier should be
taken into account.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599984/
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Prevalence of hepatitis B and hepatitis C infection in Libya:
results from a national population based survey
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24405790

BMC Infect Dis. 2014 Jan 9;14(1):17.

Prevalence of hepatitis B and hepatitis C infection in Libya: results from
a national population based survey.

Daw MA, El-Bouzedi A; In association with Libyan Study Group of Hepatitis
& HIV.

BACKGROUND: Libya is one of the largest countries in Africa and has the
longest coast in the Mediterranean basin facing southern Europe. High
rates of prevalence of viral hepatitis have been observed in various
regions in Africa, but the prevalence in Libya is not well documented. We
report on a large-scale nationwide study that evaluated the epidemiology
of hepatitis B and hepatitis C in Libya and assessed the risk factors
involved.

METHODS: A cross-sectional study was carried out in 2008 on 65,761
individuals all over Libya. The country was divided into 12 regions
according to the population density and sampling within each region was
carried out under the supervision of the National Centre for Prevention of
Infectious Diseases. Serum samples were collected from both males and
females of all ages in both urban and rural areas and tested for HBsAg for
hepatitis B and anti-HCV antibody for hepatitis C. Prevalence rates were
determined in regions and in different groups and correlated with
different demographic and risk factors involved in the spread of these
viruses.

RESULTS: The prevalence of hepatitis B and hepatitis C viruses varied
regionally across the country. The overall prevalence of hepatitis B was
2.2% (95% CI 2.1%-2.3%) and was higher among males than females (1.4:1.0).
Hepatitis C virus (HCV) prevalence was 1.2% (95% CI 1.1-1.3) and it
increased gradually after the age of 30 years (0.7-0.9% for?<?30 years;
3.6% for?=?60 years). Prevalence of HBsAg was 0.8-0.9% below the age of 10
years, and higher but similar in older age groups (2.3-2.7%). There was an
association between literacy and prevalence of hepatitis, particularly for
HCV. Hospital admission, surgical operation, blood transfusion, and
intravenous drug use were the main risk factors, and they were associated
independently with a higher prevalence rate of viral hepatitis.

CONCLUSIONS: Libya may be considered an area of low-intermediate
endemicity for hepatitis B virus infection, with lower rates in young age
groups, and an area of low endemicity for hepatitis C. The prevalence of
hepatitis B and C across Libya is not homogeneous, with indications of the
effect of the higher rates in some neighbouring countries. Libya should
adopt full coverage national plans and guidelines to face the future
consequences of viral hepatitis, particularly hepatitis C virus.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3893419/
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Intravitreal injections: a review of the evidence for best
practice
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23078366

Clin Experiment Ophthalmol. 2013 Jul;41(5):500-7.

Intravitreal injections: a review of the evidence for best practice.

Fagan XJ, Al-Qureshi S.

Intravitreal injection is a common procedure performed by
ophthalmologists. It is a quick and targeted treatment for a number of
ophthalmic conditions. Despite this, the potential to cause serious
complications and patient discomfort cannot be ignored.

This article presents the level of evidence in the scientific literature
supporting common practices such as location of the procedure, anaesthetic
choice, sterile procedure techniques, comparison of some common
pharmaceutical agents and the use of antibiotics.

© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal
Australian and New Zealand College of Ophthalmologists.

Comment in
Intravitreal injections: a most recent evidence for best practice. [Clin
Experiment Ophthalmol. 2013]

Intravitreal injections: a most recent evidence for best practice–
response. [Clin Experiment Ophthalmol. 2013]
__________________________________________________________________
________________________________*_________________________________

10. Abstract: A Patient with Fatal Necrotizing Fasciitis following the Use
of Intra-Articular Sodium Hyaluronate Injections: A Case Report
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24454403

Case Rep Med. 2013;2013:531794.

A Patient with Fatal Necrotizing Fasciitis following the Use of Intra-
Articular Sodium Hyaluronate Injections: A Case Report.

Virupannavar S1, Guggenheim C2.

Introduction. Osteoarthritis, a degenerative joint disease, is a key cause
of disability around the world and an ever-growing public health concern.
Intra-articular hyaluronic acid viscosupplementation is used as a
conservative option for osteoarthritis knee pain relief (McArthur et al.,
2012; Hootman and Helmick, 2006; Huang el al., 2011).

In general, the literature has shown an excellent safety profile for this
treatment modality (McArthur et al., 2012; Clegg et al., 2013; Hammesfahr
et al., 2003; Neustadt et al., 2005; Cohen et al., 2008; Neustadt, 2003;
Jüni et al., 2007; Peterson and Hodler, 2011).

Case Presentation. In this report, we describe a case of a woman who had
received multiple sodium hyaluronate injections and developed severe
necrotizing fasciitis near the injection site.

Conclusion. We recommend that clear guidelines for clean technique be put
in place for use with sodium hyaluronate injections and consideration of
full sterile technique in immunosuppressed patients.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881447/
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Intra-articular hyaluronic acid injection versus oral non-
steroidal anti-inflammatory drug for the treatment of knee
osteoarthritis: a multi-center, randomized, open-label, non-
inferiority trial
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24443804

Arthritis Res Ther. 2014 Jan 21;16(1):R18.

Intra-articular hyaluronic acid injection versus oral non-steroidal anti-
inflammatory drug for the treatment of knee osteoarthritis: a multi-
center, randomized, open-label, non-inferiority trial.

Ishijima M, Nakamura T, Shimizu K, Hayashi K, Kikuchi H, Soen S, Omori G,
Yamashita T, Uchio Y, Chiba J, Ideno Y, Kubota M, Kurosawa H, Kaneko K.

INTRODUCTION: While many of the commonly used conservative treatments for
knee osteoarthritis (OA) have been recognized to be effective, there is
still insufficient evidence available. Among the pharmacological
treatments for knee OA, oral non-steroidal anti-inflammatory drugs
(NSAIDs) act rapidly and are recommended for the management of OA.
However, frequent and serious adverse effects of NSAIDs have been
recognized. Intra-articular injections of hyaluronic acid (IA-HA) for the
treatment of knee OA have been shown to reduce pain and improve joint
function. However, there has been no qualified direct comparison study of
efficacy and safety between IA-HA and NSAIDs for patients with knee OA.
The aim of this study was to clarify the efficacy and safety of early-
phase IA-HA in comparison to those of NSAID for patients with knee OA.

METHODS: This multi-center, randomized, open-label, parallel-group, non-
inferiority comparison study with an oral NSAID involved a total of 200
patients with knee OA. An independent, computer-generated randomization
sequence was used to randomly assign patients in a 1:1 ratio to NSAID 3
times per day for five weeks (n = 100) or IA-HA once a week for five weeks
(n = 100). The primary endpoint was the percent change in the patient-
oriented outcome measure for knee OA, the Japanese Knee Osteoarthritis
Measure (JKOM) score. All patients were questioned regarding any adverse
events during treatment. The full analysis set (FAS) was used for
analysis. The margin of non-inferiority was 10%.

RESULTS: The analyses of primary endpoint included 98 patients in the IA-
HA group and 86 patients in the NSAID group. The difference in the percent
changes of JKOM score between the two intervention arms (IA-HA; -34.7% (P
<0.001), NSAID; -32.2% (P <0.001)) was -2.5% (95% confidence interval
(CI): -14.0 to 9.1), indicating IA-HA was not inferior to NSAID. The
frequency of both withdrawal and adverse events in the IA-HA group were
significantly lower than those in the NSAID group (P = 0.026 and 0.004,
respectively).

CONCLUSIONS: The early efficacy of IA-HA is suggested to be not inferior
to that of NSAIDs, and that the safety of early-phase of IA-HA is superior
to that of NSAIDs for patients with knee OA.

Trial registration: UMIN Clinical Trials Registry (UMIN-CTR),
UMIN000001026.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Improving waste segregation while reducing costs in a
tertiary-care hospital in a lower-middle-income country in Central
America
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23592758

Waste Manag Res. 2013 Jul;31(7):733-8.

Improving waste segregation while reducing costs in a tertiary-care
hospital in a lower-middle-income country in Central America.

Johnson KM, González ML, Dueñas L, Gamero M, Relyea G, Luque LE, Caniza
MA.

Healthcare waste (HCW) management and segregation are essential to ensure
safety, environmental protection and cost control. Poor HCW management
increase risks and costs for healthcare institutions. On-going
surveillance and training are important to maintain good HCW practices.

Our objectives were to evaluate and improve HCW practices at Hospital
Bloom, San Salvador, El Salvador. We studied HCW disposal practices by
observing waste containers, re-segregating waste placed in biohazardous
waste bags, and administering a seven-items knowledge survey before and
after training in waste management at Hospital Bloom. The training was
based on national and international standards. We followed total
biohazardous waste production before and after the training.

The hospital staff was knowledgeable about waste segregation practices,
but had poor compliance with national policies. Re-segregating waste in
biohazardous waste bags showed that 61% of this waste was common waste,
suggesting that the staff was possibly unaware of the cost of mis-
segregating healthcare waste.

After staff training in HCW management, the correct responses increased by
44% and biohazardous waste disposal at the hospital reduced by 48%. Better
segregation of biohazardous waste and important savings can be obtained by
HCW management education of hospital staff.

Hospitals can benefit from maximising the use of available resources by
sustaining best practices of HCW, especially those in hospitals in lower-
middle-income countries.

KEYWORDS: Resource-limited country, cost reduction, education, infection
prevention, medical waste
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Treatment as prevention among injecting drug users;
extrapolating from the Amsterdam cohort study
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24401639

AIDS. 2014 Jan 7.

Treatment as prevention among injecting drug users; extrapolating from the
Amsterdam cohort study.

de Vos AS, Prins M, Coutinho RA, van der Helm JJ, Kretzschmar ME.

OBJECTIVE:: To determine the potential of treatment as prevention for
reducing HIV incidence among injecting drug users (IDU).

METHODS:: Transmission dynamics of HIV as influenced by cART uptake and
demographic changes were studied using an individual-based model.
Parameters were based on data of the Amsterdam Cohort Study, and
counterfactual treatment scenarios were examined for this city. Demography
of the modeled population was also varied to allow for more general
conclusions.

RESULTS:: We estimated that over the complete HIV epidemic among IDU in
Amsterdam the historic use of cART has led to only 2% less incidence. As
individuals were treated from low CD4-counts, their decreased
infectiousness was offset by increased infectious lifetime. Large
reduction in incidence could result from a test and immediate treat
strategy, with elimination of HIV occurring when the average time from
infection to starting treatment was less than 2 months. However,
substantial proportions of new infections were prevented only if the test
and treat intervention was implemented within the first few years after
HIV-epidemic onset, especially for a declining IDU population. Ignoring
heterogeneity in risk-behavior led to overly optimistic expectations of
the prevention effects of treatment. In general, treatment led to much
greater reduction in incidence compared with stopping HIV+ IDU from
lending out syringes.

CONCLUSION:: A test and immediate treat strategy for HIV among IDU could
lead to great reductions in incidence. To fully eliminate the spread of
HIV, treatment as prevention should be combined with other interventions,
with behavioral intervention directed at those not yet HIV infected.
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Overdose prevention in injecting opioid users: The role of
substance abuse treatment and training programs
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24418018

Gac Sanit. 2014 Jan 10. pii: S0213-9111(13)00227-6.

Overdose prevention in injecting opioid users: The role of substance abuse
treatment and training programs.

Sarasa-Renedo A1, Espelt A2, Folch C3, Vecino C4, Majó X5, Castellano Y4,
Casabona J3, Brugal MT4; Redan Study Group.

OBJECTIVES: Opioid overdose is still the first cause of preventable death
among young men in Barcelona. Sound knowledge of opioid overdose
prevention is important to avoid complications and deaths. This study
aimed to identify the factors associated with limited knowledge of
overdose prevention and to assess the possible effect of treatment and
overdose prevention training programs on this variable.

METHODS: From October 2008 to March 2009, current injecting opioid users
attending harm reduction centers in Catalonia (Spain) were interviewed.
Crude and adjusted prevalence ratios of limited knowledge about overdose
prevention were calculated by adjusting Poisson regression models with a
robust variance.

RESULTS: In this sample, 28.7% of clients had limited knowledge of
overdose prevention. Factors associated with limited knowledge were
country of origin, never having received treatment for drug dependency,
having a low educational level, and never having experienced an overdose.
In contrast, treatment at the time of the interview was not associated
with a lower prevalence of limited knowledge about overdose prevention.

CONCLUSIONS: These findings suggest that preventive programs would benefit
from accounting for linguistic and educational limitations and from
participation in every treatment episode. Comprehensiveness and broad
coverage of such programs could help to maximize their impact. Copyright ©
2013 SESPAS. Published by Elsevier Espana. All rights reserved.

KEYWORDS: Analgesics, Analgésicos, Centros de tratamiento por uso de
sustancias, EU, European Union, Heroin, Heroína, IDU, Injected Drug User,
Intravenous injection, Inyección intravenosa, Opioid, Opioides, Overdose,
PR, Prevalence Ratio, Preventive health services, Servicios preventivos,
Sobredosis, Substance abuse treatment centers

Free full text http://tinyurl.com/nmet6rj
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Significant differences in clinical outcomes between HIV-
hepatitis C virus coinfected individuals with and without injection
drug use history
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24413263

AIDS. 2014 Jan 2;28(1):121-7.

Significant differences in clinical outcomes between HIV-hepatitis C virus
coinfected individuals with and without injection drug use history.

Cescon A, Chan K, Raboud JM, Burchell AN, Forrest JI, Klein MB, Loutfy MR,
Machouf N, Montaner JS, Tsoukas C, Hogg RS, Cooper C; CANOC Collaboration.

OBJECTIVE: Studies focusing on HIV-hepatitis C virus (HCV) coinfected
individuals without a history of IDU are limited. It is plausible that
poorer clinical outcomes in HIV-HCV coinfection are due to factors
associated with IDU, not from HCV itself. This study compares HIV
treatment outcomes and survival between HIV-HCV coinfected individuals
with and without IDU history.

DESIGN: Observational cohort study.

METHODS: We analyzed data from a multisite Canadian cohort study of HIV-
positive individuals initiating combination antiretroviral therapy (ART)
after 1 January 2000. This analysis was restricted to 1254 participants
with HCV coinfection and known IDU history. Cox proportional hazards
regression was used to evaluate time from ART initiation to virologic
suppression (two consecutive measures <250?copies/ml) and CD4 cell count
recovery (+100?cells/µl). In order to account for loss to follow-up
(LTFU), competing risk analysis was used to evaluate time to death.

RESULTS: A total of 1254 participants (31% women) were included. During a
median follow-up time of 3.8 years (interquartile range?=?2.1-6.2), 217
deaths were reported and 148 participants were LTFU. In adjusted
multivariable analysis, individuals with IDU history were significantly
less likely to achieve virologic suppression [adjusted hazard ratio
(AHR)?=?0.78, 95% confidence interval (CI)?=?0.64-0.95]; marginally less
likely to have CD4 cell count recovery (AHR?=?0.82, 95% CI?=?0.66-1.00);
and had a significantly higher risk of death (AHR?=?2.15, 95%
CI?=?1.25-3.70).

CONCLUSION: IDU history independently elevates risk for poorer clinical
outcomes, separate from HCV coinfection. HIV-HCV coinfected persons are
not homogeneous in characteristics or outcomes, suggesting care should be
taken during statistical analyses if attributing poorer HIV-specific
outcomes solely to HCV coinfection.
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Beginning the journey of hand hygiene compliance monitoring
at a 2,100-bed tertiary hospital in Vietnam
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24388472

Am J Infect Control. 2014 Jan;42(1):71-3.

Beginning the journey of hand hygiene compliance monitoring at a 2,100-bed
tertiary hospital in Vietnam.

Salmon S1, Tran HL2, Bùi DP2, Pittet D3, McLaws ML4.

As part of the first hospital-wide hand hygiene campaign at Hue General
Hospital, Vietnam, we audited hand hygiene compliance following health
care worker education and the introduction of alcohol-based handrub.

Alcohol-based handrub was chosen more frequently than plain soap and water
(83% and 17%, respectively; P = .0001). Hand hygiene compliance averaged
47% (1,310 actions/2,813 opportunities; 95% confidence interval: 45%-48%)
with markedly different rates among departments, ranging from 5% to 69% (P
= .0001).

Copyright © 2014 Association for Professionals in Infection Control and
Epidemiology, Inc. All rights reserved.

KEYWORDS: Adherence, Alcohol-based handrub, Handwashing, Promotion
campaign
__________________________________________________________________
________________________________*_________________________________

17. Abstract: Prospective randomized clinical trial: single and weekly
viscosupplementation
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24453681

Acta Ortop Bras. 2013;21(5):271-5.

Prospective randomized clinical trial: single and weekly
viscosupplementation.

Zóboli AA, de Rezende MU, de Campos GC, Pasqualin T, Frucchi R, de Camargo
OP.

OBJECTIVE: To compare two different dosages of an intermediate molecular
weight sodium hyaluronate (HA) (Osteonil(®)-TRB Pharma) assessing whether
a single 6 ml application of this HA has the same effectiveness as the
classical three-weekly 2 ml dose.

METHODS: 108 patients with knee osteoarthritis were randomized into two
groups of 54 patients each. The groups were designated “single” (S) and
“weekly” (W). Patients in group S underwent a viscosupplementation
procedure by application of only 6 ml of sodium hyaluronate and 1 ml
triamcinolone hexacetonide. Patients in group W underwent the procedure of
viscosupplementation through three applications with 2 ml sodium
hyaluronate with a week interval between them, and the first application
was also performed with the infiltration of 1 ml (20 mg) of Triamcinolone
Hexacetonide. Both groups were assessed before, at one month and three
months after application, by responding to the WOMAC, Lequesne, IKDC and
VAS questionnaires.

RESULTS: There was no statistical difference between the single
application of 6 ml of sodium hyaluronate and classic application with
three weekly injections. However, only the classical regime showed
statistically significant improvement in baseline pain (WOMAC pain and
VAS).

CONCLUSION: Our results suggest that both application schemes improve
application function, but the three-weekly regimen of 2 ml was more
effective in reducing pain. Level of Evidence I, Prospective Randomized,
Clinical Trial.

KEYWORDS: Hyaluronic acid/administration and dosage, Hyaluronic
acid/therapeutic use, Knee, Osteoarthritis

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3874997/
__________________________________________________________________
________________________________*_________________________________

18. Abstract: Functional outcome of collagenase injections compared with
fasciectomy in treatment of Dupuytren’s contracture
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24426958

Hand (N Y). 2013 Dec;8(4):410-6.

Functional outcome of collagenase injections compared with fasciectomy in
treatment of Dupuytren’s contracture.

Naam NH.

BACKGROUND: This study was designed to provide comparative information on
the safety and efficacy of injection with collagenase clostridium
histolyticum (CCH) and fasciectomy for patients with Dupuytren’s
contracture (DC).

METHODS: A single-center, retrospective, observational, longitudinal chart
review was conducted of 25 patients treated with CCH injections and 21
patients undergoing fasciectomy. Patients were assessed at 1 week, monthly
for 3 months and then yearly for a minimum of 2 years after treatment for
changes in contracture and range of motion, time to return to work/normal
activities, patient satisfaction, and Disabilities of Arm, Shoulder and
Hand (DASH) score.

RESULTS: Post-procedure follow-up averaged 32 months for the injection
group compared with 39 months for fasciectomy group. For the CCH group,
the mean postinjection contracture was 3.6° for the metacarpophalangeal
and 17.5° for the proximal interphalangeal joints compared with 3.7° and
8.1° in the fasciectomy group, respectively. Patients treated with
injections returned to normal activities after a mean of 1.9 days compared
with 37.4 days for fasciectomy patients (p?<?0.0001). DASH scores for 13
CCH and 15 fasciectomy patients were obtained. The mean DASH score was
significantly lower in the injection group in the first 3 months
(p?<?0.01). At the 2- year follow-up visit, patients were satisfied with
their outcomes following either treatment (92 % and 96 % of CCH and
fasciectomy patients, respectively).

CONCLUSION: CCH injections are safe and effective and may be a viable
alternative to fasciectomy for treating DC. It also allows earlier return
to work and daily activities.

KEYWORDS: Collagenase, Dupuytren’s contracture, Fasciectomy
__________________________________________________________________
________________________________*_________________________________

19. Abstract: Maladministrations in nuclear medicine: revelations from the
Australian Radiation Incident Register
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24438417

Med J Aust. 2014 Jan 20;200(1):37-40.

Maladministrations in nuclear medicine: revelations from the Australian
Radiation Incident Register.

Larcos GS1, Collins LT2, Georgiou A3, Westbrook JI3.

OBJECTIVE: To describe the incidence, type, causes and consequences of
nuclear medicine maladministrations.

SETTING AND PARTICIPANTS: Review of prospectively acquired
maladministration reports within the Australian Radiation Incident
Register (ARIR), a mandatory incident register managed by the Australian
Radiation Protection and Nuclear Safety Agency.

MAIN OUTCOME MEASURES: Individual reports from 2007 to 2011 were evaluated
for dose of radiation exposure and type, cause and consequence of
maladministrations. Incidence was estimated using data from Medicare
Australia.

RESULTS: There were 149 maladministrations and the estimated incidence was
5.8 per 100 000 nuclear medicine procedures (95% CI, 5.0-6.9). About half
of all maladministrations (48%) arose from an incorrect
radiopharmaceutical being prepared and/or dispensed.

Other causes included mistakenly injecting the wrong radiopharmaceutical
because of inattention (n = 27; 18.1%);

extravasations, failures in equipment or procedure leading to a non-
diagnostic study (n = 25; 16.8%); misinterpreting a request form and
performing an incorrect procedure (n = 13; 8.7%); or injecting an
incorrect patient (n = 13; 8.7%). ARIR reports focused on active rather
than latent causes. Most (n = 147) maladministrations occurred following
diagnostic procedures, and the mean effective radiation dose was 7.9 mSv
(range, 0.015-45 mSv). Two therapeutic maladministrations likely caused
unintended organ injury.

CONCLUSIONS: The ARIR provides unique insight into the type, causes and
complications of maladministrations in Australia. Nearly all
maladministrations occur in a diagnostic context, and the risk of patient
harm appears low. Among active causes, radiopharmaceutical preparation and
dispensation, and medical supervision before injection merit attention.
The ARIR could be refined by attending to latent errors, addressing
possible underreporting and securing more complete Medicare data.
__________________________________________________________________
________________________________*_________________________________

20. Abstract: Evaluation and treatment of accidental autoinjection of
epinephrine
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23592360

Am J Health Syst Pharm. 2013 May 1;70(9):778-81.

Evaluation and treatment of accidental autoinjection of epinephrine.

Peyko V, Cohen V, Jellinek-Cohen SP, Pearl-Davis M.

PURPOSE: A case of accidental autoinjection of epinephrine is described.

SUMMARY: A 47-year-old man arrived at the emergency department after
accidental injection of epinephrine with an autoinjector into his left
thumb. His vital signs were stable at admission. The patient was allergic
to nuts and thought he may have eaten something containing a pine nut. The
patient reported feeling itching in his throat but had no shortness of
breath or swollen tongue. He tried to self-administer an epinephrine
injection, but it did not inject. While he was checking the device, it
accidently injected into his left thumb pad.

A review of systems revealed throat discomfort, a tingling sensation of
the tongue, and a left-thumb puncture with pain. Physical examination of
the left thumb pad revealed a pale, cool thumb with diminished capillary
refill and punctuate black discoloration at the site of injection.

Topical nitroglycerin paste was applied but had no effect, so terbutaline
was ordered. The terbutaline injection was prepared as a 1:1 preparation
of terbutaline sulfate 1 mg/mL and 0.9% sodium chloride injection. The
immediate effects were the return of color from pale white to red and
observable perfusion to the area within seconds. After 20 minutes, the red
color remained, with observable perfusion and warmth, in addition to
complete neurosensory function. Sixty minutes after terbutaline
administration, the patient was discharged home.

CONCLUSION: A 47-year-old man who accidentally injected himself in the
thumb with an epinephrine autoinjector was successfully treated with
subcutaneous terbutaline. The treatment had an immediate effect, including
revascularization and resolution of pain.
__________________________________________________________________
________________________________*_________________________________

21. No Abstract: In regard to the paper: Developments in the necessity and
coverage of the syringe exchange program in Spanish prisons,
1992-2009. Estimation after correction
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23529367

Rev Esp Sanid Penit. 2013;15(1):37-8.

[In regard to the paper: Developments in the necessity and coverage of the
syringe exchange program in Spanish prisons, 1992-2009. Estimation after
correction].

[Article in Spanish]

Acín García EJ.

Comment on
[Evolution of the need and coverage of syringe exchange programs in
Spanish prisons, 1992-2009: A revised estimation]. [Rev Esp Sanid Penit.
2012]

Free full text
__________________________________________________________________
________________________________*_________________________________

22. No Abstract: Mitigating the risk of HIV infection with opioid
substitution treatment
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23554530

Bull World Health Organ. 2013 Feb 1;91(2):148-9.

Mitigating the risk of HIV infection with opioid substitution treatment.

Gowing LR, Hickman M, Degenhardt L.

Free Article http://www.who.int/bulletin/volumes/91/2/12-109553.pdf
__________________________________________________________________
________________________________*_________________________________

23. No Abstract: Knowledge, attitude and practice towards infection
control among healthcare professionals
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24067011

Natl Med J India. 2013 Jan-Feb;26(1):59-60.

Knowledge, attitude and practice towards infection control among
healthcare professionals.

Gupta A, Kapil A, Lodha R, Sreenivas V.
__________________________________________________________________
________________________________*_________________________________
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