Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices

Effect of orientation angle for needle-free jet injection

In this paper, we report on the delivery efficiency of needle-free jet injections using injectors with typical jet speed vj≈140m/s, orifice diameter do=157μm, and volume V=0.1 mL. The target substrates were either hydrogel tissue phantoms or porcine tissues combined with excised human skin. The novelty of this study is two-fold: First, we investigate the influence of injection angle relative to the skin surface, and second, we also study the influence of the jet path relative to the orientation of muscle fibers. While most commercial jet injectors employ a fitting that would render the device normal to the skin surface, recent studies have proposed oblique injections, which may be beneficial for intradermal or subcutaneous tissue injection. Furthermore, for deeper intramuscular injections, we propose that an angled jet path taking the muscle fiber orientation into account may result in a bolus or dispersion zone that is conducive to increased cellular uptake of the drug.

Implementing long-acting injectable antiretroviral treatments in Senegal: issues, challenges and conditions for introducing them. Qualitative study with healthcare providers and patients

Long-acting injectable antiretroviral therapy (LAI-ART) can offer people living with HIV (PLWH) a promising alternative to daily oral therapy. This article highlights the issues, challenges and conditions related to introducing LAI-ART into the social lives of PLWH and HIV-care practices in Senegal. Semi-structured interviews were conducted with 42 PLWH in two hospital care units in Dakar and with 13 healthcare providers and 6 peer educators. Interviews were transcribed, thematically coded and analysed using a cross-sectional approach. We found three key issues. First, simplifying living with HIV: PLWH respondents perceive LAI-ART as an opportunity to ease the burden associated with taking tablets. This enthusiasm may however be qualified by an ambivalent relationship with injections and is subject to certain conditions. Second, certain constraints linked to the medicalisation of care are to be anticipated, including the obligation to go to the hospital every two months for injections. These findings foreshadow the new management work for medical follow-up expected to fall on PLWH and caregivers. Third, the challenges of introducing LAI-ART in Senegal are to ensure adequate organisation of care and supply and sustainability of the program. These results clarify how to implement programs to introduce LAI-ART into real life in the West African context.

Potential for Kappa-Opioid Receptor Agonists to Engineer Nonaddictive Analgesics: A Narrative Review

A serious adverse effect of prescription opioid analgesics is addiction, both to these analgesics and to illicit drugs like heroin that also activate the µ-opioid receptor (MOR). Opioid use disorder (OUD) and opioid overdose deaths represent a current American health crisis, and the prescription of opioid analgesics has contributed significantly to this crisis. While prescription opioids are highly effective analgesics, there currently exists no facile way to use them for extended periods without the risk of addiction. If addiction caused by MOR-targeting analgesics could be blocked by blending in a new "antiaddiction" ingredient that does not diminish analgesia and does not introduce its own therapeutically limiting side effects, then continued clinical use of prescription opioids for treating pain could be maintained (or even enhanced) instead of curtailed. In this narrative review, we contextualize this hypothesis, first with a brief overview of the current American opioid addiction crisis. The neurobiology of 2 key receptors in OUD development, MOR and the κ-opioid receptor (KOR), is then discussed to highlight the neuroanatomical features and circuitry in which signal transduction from these receptors lie in opposition-creating opportunities for pharmacological intervention in curtailing the addictive potential of MOR agonism. Prior findings with mixed MOR/KOR agonists are considered before exploring new potential avenues such as biased KOR agonists. New preclinical data are highlighted, demonstrating that the G protein-biased KOR agonist nalfurafine reduces the rewarding properties of MOR-targeting analgesics and enhances MOR-targeting analgesic-induced antinociception. Finally, we discuss the recent discovery that a regulator of G protein signaling (namely, RGS12) is a key component of signaling bias at KOR, presenting another drug discovery target toward identifying a single agent or adjuvant to be added to traditional opioid analgesics that could reduce or eliminate the addictive potential of the latter drug.

Perspectives of injectable long acting antiretroviral therapies for HIV treatment or prevention: understanding potential users' ambivalences

Recent clinical trial data showed that injectable long-acting antiretroviral treatment (LA-ART) every four or eight weeks could become an alternative option for HIV treatment or prevention. The purpose of our study was to explore perceptions and potential users' points of views of this new mode of administration through individuals' therapeutic itinerary and their singular history with ART. Between 2018 and 2019, a qualitative study was conducted in two University Hospitals in Paris, France. In-depth interviews were conducted with 15 virologically controlled People Living with HIV (PLWH) and 13 men on pre-exposure prophylaxis (PrEP) for at least six months. Interviews, focused on the daily experience with ART, were recorded, transcribed, and analyzed using thematic content analysis. Collected discourses were organized around three emergent concerns: social, material and experimental. Each of these concerns was perceived as ambivalent, balanced by skepticism and hope. It revealed the complexity of each individual's relationship to their HIV treatment or PrEP, leading to balance the injectable LA-ART popularity reported within clinical trials. This new mode of administration may be a suitable alternative for some PLWH and PrEP users, a "simplification" compared to the oral route. It opens a window for "customizable" ART-treatment according to individuals' lives.

Mass screening for hepatitis B and C in Southern Upper Egypt

Background

It is well documented that Egypt has the highest prevalence of hepatitis C virus (HCV) infection in the world. The recent development of highly effective direct acting antiviral drugs (DAAs), has opened the possibility of treating and curing HCV infection in the Egyptian population on a large scale.

Methods

A screening demonstration project was implemented in southern Egypt in and around the city of Luxor. Free screening and if indicated, treatment, was offered to those 16 years or older for anti-HCV antibodies (anti-HCV) and hepatitis B surface antigen (HBsAg) using third generation enzyme immunoassays (Enzygnost® Anti-HCV and HbsAg). Statistical methods included estimation of odds ratios (OR) and 95% confidence intervals (95% CI).

Results

There was a large turnout of 67,042 persons who were screened in a 12-month period starting in June 2016. Thirty-one thousand nine hundred sixty-four males (47.7%) and 35,074 females (52.3%) were screened with a mean age of 43.6 ± 14.3 years. Nine thousand seven hundred one patients (14.5%) were positive for anti-HCV and 2950 (4.4%) for HBsAg. Prevalence of anti-HCV was significantly higher in males than females (19.67% vs.9.73% OR = 2.27; CI 2.2 to 2.4; p < 0.001) and the same for HBsAg (6.2% vs. 2.8% OR = 2.3; CI 2.2 to 2.5; p < 0.001). The prevalence of anti-HCV was significantly associated with age (p < 0.001), ranging from between 1 and 4% in individuals below the age of 40 years, then increased steadily to 42% at age 60 followed by a precipitous decline in age specific prevalence.

Conclusions

The results showed unanticipated patterns in the Luxor area of anti-HCV and HBsAg by age and gender in contrast to previous reports on this unique HCV epidemic in Egypt. Moreover, the level and rate of turnout, cost, and other logistical issues, provided essential information for effective planning, design, and evaluation methods for larger national mass screening and treatment programs.

Acceptability and Feasibility of Delivering Pentavalent Vaccines in a Compact, Prefilled, Autodisable Device in Vietnam and Senegal

BACKGROUND

Prefilled syringes are the standard in developed countries but logistic and financial barriers prevent their widespread use in developing countries. The current study evaluated use of a compact, prefilled, autodisable device (CPAD) to deliver pentavalent vaccine by field actors in Senegal and Vietnam.

METHODS

We conducted a logistic, programmatic, and anthropological study that included a) interviews of immunization staff at different health system levels and parents attending immunization sessions; b) observation of immunization sessions including CPAD use on oranges; and c) document review.

RESULTS

Respondents perceived that the CPAD would improve safety by being non-reusable and preventing needle and vaccine exposure during preparation. Preparation was considered simple and may reduce immunization time for staff and caretakers. CPAD impact on cold storage requirements depended on the current pentavalent vaccine being used; in both countries, CPAD would reduce the weight and volume of materials and safety boxes thereby potentially improving outreach strategies and waste disposal. CPAD also would reduce stock outages by bundling vaccine and syringes and reduce wastage by using a non-breakable plastic presentation. Respondents also cited potential challenges including ability to distinguish between CPAD and other pharmaceuticals delivered via a similar mechanism (such as contraceptives), safety, and concerns related to design and ease of administration (such as activation, ease of delivery, and needle diameter and length).

CONCLUSIONS

Compared to current pentavalent vaccine presentations in Vietnam and Senegal, CPAD technology will address some of the main barriers to vaccination, such as supply chain issues and safety concerns among health workers and families. Most of the challenges we identified can be addressed with health worker training, minor design modifications, and health messaging targeting parents and communities. Potentially the largest remaining barrier is the marginal increase in pentavalent cost--if any--from CPAD use, which we did not assess in our study.

Patient factors affecting frequent potential unnecessary injection use in outpatient care setting

This study aimed to investigate the prevalence of potential unnecessary injection (PUNI) and to identify factors associated with frequent PUNI uses. Population-based National Health Insurance claims data for outpatient health care settings during the six month period from July to December 2011 were retrospectively reviewed. Patients aged 18-80 without severe diseases and visited healthcare centers more than 25 times during study period were included. PUNI was defined as injection used where substitutable oral agents were available and where injection uses are not warranted. A total of 801,532 patients were included for this analysis. Among them, 29.0 % were frequent PUNI user defined as ≥10 PUNI used during the study period. In multivariate logistic regression results revealed significant associations between frequent PUNI use and several patient and healthcare utilization factors. Women than men, elderly than younger people, residents in rural areas than in big cities, and more frequent visitors to healthcare centers than less frequent visitors were more likely to be frequent PUNI users. Larger number of healthcare center utilized and higher out-of-pocket expense level showed significant lower risks of frequent PUNI uses. Identified factors associated with frequent PUNI use in this study could be the targets to develop programs for reducing injection overuse.

The cross-level impact of patient safety climate on nursing innovation: a cross-sectional questionnaire survey

AIMS AND OBJECTIVES

To explore the cross-level effects of the four dimensions of patient safety climate on nursing innovation.

BACKGROUND

Across the globe, nursing innovation is highly encouraged by nursing experts to improve nursing outcome. Nursing innovation, in turn, is affected by organisational climate, and a critical aspect of organisational climate is patient safety.

DESIGN

This is a cross-sectional study.

METHODS

We employed a questionnaire survey to collect data and selected nurses from Taiwan hospitals as samples. A total of 808 valid questionnaires in 172 teams of four hospitals were collected. Patient safety climate was aggregated by individual-level data; thus, we examined r(wg) , ICC 1 and ICC 2. Hierarchical linear modelling was used to analyse the data.

RESULTS

Of these three dimensions of nursing innovation, the level of knowledge creation was perceived by the nurses as the highest. In terms of patient safety climate, managerial practices regarding patient safety scored the highest, followed by patient safety procedures, patient safety information flow and patient safety priority. Only patient safety information flow yielded a significant positive influence on knowledge creation, innovation behaviour or innovation diffusion.

CONCLUSION

Hospital nurses do achieve better performance in knowledge creation. Patient safety information flow has positive and cross-level impact on nursing innovation; therefore, the method to increase safety information flow is the key focus of nursing innovation management.

RELEVANCE TO CLINICAL PRACTICE

Through the improvements made in patient safety climate, hospital managers could promote the development of nursing innovation. Patient safety information flow is positively associated with nursing innovation. Patient safety information could be integrated in nursing training in all levels. Rules and procedures regarding patient safety should be drafted in simple and clear terms. A procedure to review and revise the rules and procedures will also be helpful in improving patient safety information flow.

Appropriation and dementia in India

Biomedical technologies like MRI scans offer a way for carers and people with dementia to 'see' pathology, as a means to reorient their perceptions of the body and functionality. Through interpretive and syncretic processes, the MRI and the diagnosis of dementia facilitate the incorporation of the clinical category 'dementia' into social understandings of illness and care in India. Complex shifts occur as families and providers move from socio-cultural explanations of disruption to bio-social etiologies of the disease 'dementia' and then to socio-ecological frameworks of causality. Both the biomedicalisation of illness and the localisation of illness occur as the clinical category 'dementia' is folded into local understandings of illness and care. Through elucidating how the dialectic between biomedical and local knowledge is operationalized, we offer insights into how dementia is absorbed and appropriated into Indian cultural contexts.

Haitian picuristes/injectionists as alternatives to conventional health care providers in South Florida

Barriers in seeking access to conventional health care services continue to be a problem in the United States, especially among recent racial and ethnic immigrants who tend to be least able to afford adequate health insurance coverage. Ethnic immigrants sometimes seek out traditional healers as unconventional providers of health care services to overcome barriers in accessing the conventional health care delivery system. The purpose of this work is to provide insight into the practices of Picuristes or Haitian "lay injectionists" in their role as alternative, unconventional providers of health care services among Haitian immigrants in South Florida. Based on in-depth interviews with 10 picuristes who were identified through venue and snowball sampling and who volunteered to participate in a larger exploratory study that examined various aspects of picuriste practices, findings revealed benefits and risks of seeking health care services from these traditional practitioners. Among the benefits reported to their services were greater accessibility, affordability, convenience, and cultural compatibility. Risks observed from analysis of picuriste interviews included the lack of formal medical training for picuristes, their nonadherence to established standards for safe injections and their potential to expose clients and the community to contaminated needles, syringes, and other biohazardous waste materials. Insight was also gained into how picuristes learned to practice their trade and to incorporate Haitian cultural beliefs regarding the relationship between clients and healers. Given the continuation of barriers to health care among ethnic immigrants, implications for conventional heath care practice and social policy are also discussed.

Correlates of picuriste use in a sample of health-seeking Haitian immigrants and adult children of immigrants in Miami-Dade County, Florida

OBJECTIVES

We explored covariates of the use of picuristes (traditional health workers with no formal medical training who provide intramuscular, subcutaneous, and intravenous injections, typically with nonsterile needles) in the Haitian community of Miami-Dade County, Florida.

METHODS

We surveyed a community-based sample of 205 Haitian immigrants and adult children of Haitian immigrants. Through logistic regression analysis, we sought to corroborate the correlates of picuriste use identified in previous qualitative interviews of picuristes and their clients.

RESULTS

Picuriste injections had been obtained by 17.6% of our respondents. After control for demographic characteristics, we found that participants who reported that a trusted person recommended a picuriste were 3.9 times as likely as participants without a recommendation to have used a picuriste. Similarly, participants who believed that the benefits associated with picuriste use were worth any resulting problems were 4.5 times as likely as those without this belief to have patronized a picuriste.

CONCLUSIONS

A significant minority of our sample patronized picuristes. Our data identified factors associated with picuriste use and shed light on a frequently hidden cultural health behavior.

Improved injection safety after targeted interventions in the Syrian Arab Republic

OBJECTIVES

Concerns about unsafe injection practices and possible infections with blood-borne pathogens in the Syrian Arab Republic motivated an assessment of the injection safety situation in the country in July 2001. In light of the recommendations from this assessment, the Ministry of Health of Syria, with the assistance of WHO, implemented a set of activities under the 'Focus Project', which aims to ensure immunization safety. The first phase of the project ran from May 2002 to February 2004, and consisted of the improved provision of injection safety equipment and supplies, the elaboration and wide distribution of national guidelines on injection safety and safe waste management, a behaviour change and communication campaign targeting the general public, and comprehensive training of healthcare workers. A follow-up survey was carried out in February 2004, 2 years after initiation of the project.

METHODS

Two representative surveys were conducted using a standardized assessment tool. A cluster sampling strategy, with probability proportionate to the population size, led to the inclusion of 80 health facilities in eight districts in 2001 and of 120 health facilities in 12 districts in 2004.

RESULTS

Injection practices had significantly improved 2 years after the start of the project. The 2001 study had pointed to a low, but non-negligible risk to patients (2% unsafe injections), coupled with a high risk to healthcare workers (61% reported needle-stick injuries in the last 12 months) and to the communities owing to unsafe waste disposal (sharps waste found outside 37% of health facilities, waste disposal considered unsafe in 48% of them). The 2004 survey showed that 90% of Syrian healthcare workers had received training in injection safety. All injections observed were given safely (difference to 2001 not significant), although some problems in preparation and reconstitution prevailed. The risk to healthcare workers was significantly reduced as only 14% of the staff reported needle-stick injuries (p < 0.001). The risk to the communities was notably decreased following improvements in sharps waste management (sharps were found in the surroundings of only 13% of health facilities, p < 0.001).

CONCLUSIONS

The example of Syria shows that rapid improvement in injection safety is possible and that the necessary tools and methods to monitor and evaluate progress are at our disposal. Challenges remain in transferring this successful programme from the well-structured immunization programme to the more diverse curative health services.