High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics

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

OBJECTIVES

Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine's harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine's public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine's current and emerging contexts.

METHODS

To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors.

RESULTS

We describe xylazine's major harm domains-acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine's epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context.

CONCLUSIONS

Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.

Prevalence and factors associated with chronic venous insufficiency, leg ulceration and deep-vein thrombosis among people who inject drugs in London, UK

INTRODUCTION

People who inject drugs (PWID) are vulnerable to a range of harms, including vascular conditions such as chronic venous insufficiency (CVI), leg ulcers and deep vein thrombosis (DVT). The extent of vascular conditions has rarely been studied, despite contributing to considerable illness and disability among PWID. We assess the prevalence and associations of vascular conditions in PWID in London, UK.

METHODS

Survey data from the community-recruited Care and Prevent Study of PWID in London were analysed. Participants were asked about CVI and leg ulcers using pictorial questions, and if they had ever been diagnosed with DVT. Associations between vascular conditions and demographic/drug-use information were explored using univariate and multivariable logistic regression.

RESULTS

Among participants (n = 455), the prevalence of CVI, leg ulcers and DVT was 13% (n = 57), 10% (n = 46) and 23% (n = 105), respectively. CVI and DVT were positively associated with injecting into the groin, while injecting into the leg was positively associated with leg ulcers and DVT. CVI was also associated with not cleaning injection sites and diagnosed hepatitis C virus, and DVT with hepatitis C virus.

DISCUSSION AND CONCLUSION

The prevalence of vascular problems among PWID in London is very high in comparison to the general population. These conditions are primarily associated with injection into the femoral vein. Use of these injection sites indicates peripheral venous access problems. There is a need to reinvigorate safe injection information provision in harm reduction services, with attention to reducing risk practices associated with venous damage and transitions to femoral injection.

Deep Vein Thrombosis in Intravenous Drug Users: An Invisible Global Health Burden

The prevalence of intravenous drug use has increased in the past decade and it represents an important risk factor for deep vein thrombosis. Intravenous drug use is a global problem, with the main culprit being heroin. Peer pressure and poverty in high-risk groups such as sex workers, females, and young adults raise the risk of intravenous drug use, which expresses itself in the form of venous thromboembolism eventually. Deep vein thrombosis typically manifests itself eight years after the initial intravenous drug administration, rendering it a silent killer. Aiming to review and summarize existing articles in this context, we performed an exhaustive literature search online on PubMed and Google Scholar indexes using the keywords "Deep Venous Thrombosis (DVT)" and "Intravenous Drug Users (IVDU)." English articles that addressed epidemiology, pathogenesis, clinical manifestations, diagnosis, differential diagnosis, management, and outcomes of DVT, including those in IVDU, were selected and analyzed. The pathogenesis of DVT development in IVDU is mainly attributed to the interplay of trauma to the vessel by repeated injection and the injected drug itself. The right-sided femoral vein is the most common vein affected. Prevalent clinical presentations include local pain, swelling, and redness with typical systemic symptoms including fever, cough, dyspnea, and chest pain on top of addiction features. There appeared to be a delay in reporting symptoms, which was most likely due to the social stigma attached to IVDU. There are over 50 conditions that present with swollen and painful limbs comparable to DVT in IVDU, making precise diagnosis critical for timely treatment. Venous ultrasound is the method of choice for diagnosing DVT. Extended anticoagulant therapy with low-molecular-weight heparin combined with warfarin is the recommended treatment. Intravenous drug abusers having DVT are affected by multiple complications and poorer outcomes such as slower recovery, recurrent venous thromboembolism (VTE), and a longer hospital stay, which put them at higher risk of morbidity, mortality, reduced productivity, and economic burden.

Injecting drug use, the skin and vasculature

Damage to the skin, subcutaneous tissues and blood vessels are among the most common health harms related to injecting drug use. From a limited range of early reports of injecting-related skin and soft tissue damage there is now an increasing literature relating to new drugs, new contaminants and problems associated with unsafe injection practices. Clinical issues range from ubiquitous problems associated with repeated minor localised injection trauma to skin and soft tissue and infections around injection sites, to systemic blood infections and chronic vascular disease. The interplay of limited availability and access to sterile injecting equipment, poor injecting technique, compromised drug purity, drug toxicity and difficult personal and environmental conditions give rise to injection-related health harms. This review of injecting-related skin, soft tissue and vascular damage focuses on epidemiology and causation, clinical examination and investigation, treatment and prevention.

[Treatment strategies and outcomes for injection-associated inguinal perivascular abscesses in intravenous drug addicts]

Hintergrund

Langzeitdrogenabhängige präsentieren sich nach dem Verbrauch der oberflächlichen Venen regelmäßig mit tiefen inguinalen vaskulär assoziierten Abszessen infolge fortgesetzter Drogeninjektionen. Die Behandlung dieser Komplikationen stellt anhaltend eine große medizinische Herausforderung dar. Bisher werden keine einheitlichen Therapieregime in der Literatur beschrieben.

Fragestellung

Welche Behandlungsstrategien und Ergebnisse gibt es bei injektionsassoziierten inguinalen perivaskulären Abszessen bei Drogenabhängigen?

Material und Methoden

Die Daten aller im Zeitraum zwischen 01.01.2004 und 31.05.2019 am Universitätsklinikum Augsburg behandelten Drogenkonsumenten wurden retrospektiv aufgearbeitet und mit der vorliegenden Literatur verglichen.

Ergebnisse

Es konnten 37 Fälle (männlich = 25, weiblich = 12) nach Anwendung der Einschlusskriterien in die Datenerhebung eingeschlossen werden. Das mediane Alter im untersuchten Patientenkollektiv lag bei 34,3 Jahren. Die 30-Tage-Mortalität lag bei 2,7 % (1/37). Die Amputationsrate betrug 2,8 %. Im untersuchten Kollektiv lag bei 13 Patienten eine arterielle Beteiligung vor. In 5 Fällen wurde primär arteriell ligiert. Bei weiteren 5 Fällen wurde primär eine Rekonstruktion mittels autologen Interponats durchgeführt. In weiteren 3 Fällen erfolgte die Anlage eines Obturatorbypasses (1/3) sowie die Durchführung einer Patchplastik (2/3). Die Offenheitsrate nach arterieller Rekonstruktion lag bei 87,5 % bei einem mittleren Follow-up von 421 Tagen. Die Gesamtkomplikationsrate lag bei 51,4 %.

Diskussion

Bei vaskulärer Beteiligung ist ein situationsgerechtes Vorgehen sinnvoll. Neben der Beseitigung komplizierter, septisch-venöser Thrombosen erscheint die Korrektur arterieller Blutungen mittels autologer Rekonstruktionsmaßnahmen aussichtsreich.

Deep Vein Thromboses in Injecting Drug Users: Meanings, Bodily Experiences, and Stigma

Deep vein thromboses (DVTs) are common sequelae of injecting drugs into the groin. We explored meanings and experiences of DVTs in a group of 19 patients from the North East of England with a DVT and in treatment for opioid use. We report three themes: (a) DVT meaning making, (b) embodied experience, and (c) Stigma. Patients attributed DVTs to groin injecting, though thought other factors were also partially responsible. Medication performed both treatment and preventive functions. The most pertinent worry was amputation. Patients recognized stopping injecting as important, but it did not necessarily occur. Stigma resulted in delayed admission to hospital and feelings of isolation; support groups might alleviate the latter. Although groin injecting was undertaken partly to avoid the censure of being a drug user, ironically, a DVT led to long-standing stigmata that were discrediting signs of that exact status.

Cocaine-induced Thrombosis: Review of Predisposing Factors, Potential Mechanisms, and Clinical Consequences with a Striking Case Report

Cocaine is associated with a wide array of complications through a number of different mechanisms. Although the majority of cocaine-related morbidity has been attributed to complications in arterial vasculature, the deleterious impact of venous complications appears to be largely unrepresented in current literature as well as clinical practice despite emerging evidence of the high prevalence and annual incidence of deep vein thrombosis (DVT) in illicit drug users.

Our case report illustrates an uncharacteristic presentation of cocaine-related widespread thrombotic cascade involving both arterial and venous circulations causing significant morbidity. The complex pathophysiology of widespread prothrombotic state caused by cocaine includes endothelial damage promoting the increase of fibrinogen and Von Willebrand factor to platelet aggregation and clot formation. It is important to identify the impact cocaine-induced venous thrombosis can mount, especially in the form of potentially fatal complications like pulmonary embolism. Although recent studies have focused on increased incidence and prevalence of venous thrombosis in the setting of cocaine abuse, ours is the first case of a documented pulmonary embolism caused by cocaine-related venous thrombosis. Further studies are needed to identify patients at higher risk for this complication like rare thrombotic disorders.

The Heroin Epidemic in America: A Surgeon's Perspective

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Multidetector CT of iatrogenic and self-inflicted vascular lesions and infections at the groin

Abstract

The number and complexity of endovascular procedures performed via either arterial or venous access are steadily increasing. Albeit associated with higher morbidity compared to the radial approach, the traditional common femoral artery remains the preferred access site in a variety of cardiac, aortic, oncologic and peripheral vascular procedures. Both transarterial and venous cannulation (for electrophysiology, intravenous laser ablation and central catheterisation) at the groin may result in potentially severe vascular access site complications (VASC). Furthermore, vascular and soft-tissue groin infections may develop after untreated VASC or secondarily to non-sterile injections for recreational drug use. VASC and groin infections require rapid diagnosis and appropriate treatment to avoid further, potentially devastating harm. Whereas in the past colour Doppler ultrasound was generally used, in recent years cardiologists, vascular surgeons and interventional radiologists increasingly rely on pelvic and femoral CT angiography. Despite drawbacks of ionising radiation and the need for intravenous contrast, multidetector CT rapidly and consistently provides a panoramic, comprehensive visualisation, which is crucial for correct choice between conservative, endovascular and surgical management. This paper aims to provide radiologists with an increased familiarity with iatrogenic and self-inflicted VASC and infections at the groin by presenting examples of haematomas, active bleeding, pseudoaneurysms, arterial occlusion, arterio-venous fistula, endovenous heat-induced thrombosis, septic thrombophlebitis, soft-tissue infections at the groin, and late sequelae of venous injuries.

Teaching Points

• Complications may develop after femoral arterial or venous access for interventional procedures.

• Arterial injuries include bleeding, pseudoaneurysm, occlusion, arteriovenous fistula, dissection.

• Endovenous heat-induced thrombosis is a specific form of iatrogenic venous complication.

• Iatrogenic infections include groin cellulitis, abscesses and septic thrombophlebitis.

• CT angiography reliably triages vascular access site complications and groin infections.

Knowledge of deep vein thrombosis among intravenous drug misusers

Aims and Method

All patients attending the local supervised drug consumption clinics were surveyed over a month. They were asked via a questionnaire to list the risks of injecting drugs, particularly the symptoms and consequences of deep vein thrombosis (DVT). Of 69 patients surveyed, 46 agreed to take part.

Results

Only 9 patients (20%) had never injected drugs, whereas 16 (43%) of those injecting had injected into the groin; 10 patients (22%) had experienced a venous thrombosis themselves, and 35 (76%) knew of someone who had. Only 30 (65%) knew what a clot or thrombosis was. Pain and swelling were the most commonly reported symptoms, but few drug misusers knew of other symptoms. The best informed were those who had experienced thrombosis themselves recently.

Clinical Implications

The results indicate an apparent lack of basic knowledge about the risks of DVT in this sample of drug misusers, and a need for some new initiatives to address health education in this area for all drug misusers.

Patient autonomy and doctor's concern - a case of intravenous drug abuser

Intravenous substance abuse is often associated with physical and psychological harm, and often requires urgent medical attention. We report a case of a young male who presented with life-threatening complications of intravenous drug abuse, but refused to give details or agree to the proposed treatment, raising concerns for the team of doctors. A compos mentis patient has a right to decide what should be done to his body. Medical management or surgical interventions cannot be initiated without the patient's consent even if these are lifesaving procedures, or a procedure meant to benefit the patient. Medical practitioner can be liable for assault (criminal law), medical negligence (law of tort), damages (civil action) and even human rights issues may be raised if a patient's autonomy is not respected.

Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone

BACKGROUND

Illicit opioid use is associated with high rates of fatal and non-fatal opioid overdose. This study aims to compare rates of fatal and serious but non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone, and to identify risk factors for fatal opioid overdose.

METHODS

Opioid dependent patients treated with methadone (n=3515), buprenorphine (n=3250) or implant naltrexone (n=1461) in Western Australia for the first time between 2001 and 2010, were matched against state mortality and hospital data. Rates of fatal and non-fatal serious opioid overdoses were calculated and compared for the three treatments. Risk factors associated with fatal opioid overdose were examined using multivariate cox proportional hazard models.

RESULTS

No significant difference was observed between the three groups in terms of crude rates of fatal or non-fatal opioid overdoses. During the first 28days of treatment, rates of non-fatal opioid overdose were high in all three groups, as were fatal opioid overdoses in patients treated with methadone. However, no fatal opioid overdoses were observed in buprenorphine or naltrexone patients during this period. Following the first 28 days, buprenorphine was shown to be protective, particularly in terms of non-fatal opioid overdoses. After the cessation of treatment, rates of fatal and non-fatal opioid overdoses were similar between the groups, with the exception of lower rates of non-fatal opioid overdose in the naltrexone treated patients compared with the methadone treated patients. After the commencement of treatment, gender, and hospitalisations with a diagnosis of opioid poisoning, cardiovascular or mental health problems were significant predictors of subsequent fatal opioid overdose.

CONCLUSIONS

Rates of fatal and non-fatal opioid overdose were not significantly different in patients treated with methadone, buprenorphine or implant naltrexone. Gender and prior cause-specific hospitalisations can be used to identify patients at a high risk of fatal opioid overdose.

Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study

BACKGROUND

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

METHODS

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

RESULTS

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant.

CONCLUSION

SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Surveillance of injecting-related injury and diseases in people who inject drugs attending a targeted primary health care facility in Sydney's Kings Cross

OBJECTIVE

This study examined the prevalence of injecting-related injuries and diseases (IRIDs) and associated risk factors among people who inject drugs (PWID) attending a primary health care facility in Sydney's Kings Cross.

METHODS

We calculated prevalence of a wide range of IRIDs utilising data reported by 702 PWID who completed a clinician-administered survey at their first visit. Multivariable logistic regressions identified factors independently associated with at least one episode of: i) cutaneous and ii) non-cutaneous IRIDs.

RESULTS

Lifetime prevalence of cutaneous IRIDs was 23%. Forty-two per cent of PWID with a history of abscess attended hospital at their most recent episode. Female gender, lifetime receptive syringe sharing (RSS), injecting while in custody, and ever injecting in places other than the arm were independently associated with reporting at least one episode of cutaneous IRIDs. Ever injecting in sites other than the arm, injecting for five or more years and lifetime history of RSS were independently associated with at least one episode of non-cutaneous IRIDs.

CONCLUSIONS

IRIDs are a substantial health issue for PWID. Their ongoing surveillance is warranted particularly in primary care settings targeting PWID to inform prevention and early management, thus reducing complications that may require hospital admission.

Not in the vein: 'missed hits', subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom

BACKGROUND

The extent of intentional or accidental subcutaneous and intramuscular injections and the factors associated with these have rarely been studied among people who inject drugs, yet these may play an important role in the acquisition bacterial infections. This study describes the extent of these, and in particular the factors and harms associated with accidental subcutaneous and intramuscular injections (i.e. 'missed hits').

METHODS

People who inject drugs were recruited using respondent driven sampling. Weighted data was examined using bivariate analyses and logistic regression.

RESULTS

The participants mean age was 33 years (31% aged under 30-years), 28% were women, and the mean time since first injection was 12 years (N=329). During the preceding three months, 97% had injected heroin, 71% crack-cocaine, and 16% amphetamines; 36% injected daily. Overall, 99% (325) reported that they aimed to inject intravenously; only three aimed to inject subcutaneously and one intramuscularly. Of those that aimed to inject intravenously, 56% (181) reported ever missing a vein (for 51 this occurred more than four times month on average). Factors associated with 'missed hits' suggested that these were the consequence of poor vascular access, injection technique and/or hygiene. 'Missed hits' were twice as common among those reporting sores/open wounds, abscesses, or redness, swelling and tenderness at injection sites.

CONCLUSION

Intentional subcutaneous and intramuscular injections are rare in this sample. 'Missed hits' are common and appear to be associated with poor injection practice. Interventions are required to reduce risk through improving injecting practice and hygiene.

Fire in the vein: Heroin acidity and its proximal effect on users' health

The loss of functioning veins (venous sclerosis) is a root cause of suffering for long-term heroin injectors. In addition to perpetual frustration and loss of pleasure/esteem, venous sclerosis leads to myriad medical consequences including skin infections, for example, abscess, and possibly elevated HIV/HCV risks due to injection into larger jugular and femoral veins. The etiology of venous sclerosis is unknown and users' perceptions of cause/meaning unexplored. This commentary stems from our hypothesis that venous sclerosis is causally related to heroin acidity, which varies by heroin source-form and preparation. We report pilot study data on first ever in vivo measurements of heroin pH and as well as qualitative data on users' concerns and perceptions regarding the caustic nature of heroin and its effects. Heroin pH testing in natural settings is feasible and a useful tool for further research. Our preliminary findings, for example, that different heroin source-forms and preparations have a two log difference in acidity, have potentially broad, vital and readily implementable harm reduction implications.

Fire in the vein: Heroin acidity and its proximal effect on users' health

The loss of functioning veins (venous sclerosis) is a root cause of suffering for long-term heroin injectors. In addition to perpetual frustration and loss of pleasure/esteem, venous sclerosis leads to myriad medical consequences including skin infections, for example, abscess, and possibly elevated HIV/HCV risks due to injection into larger jugular and femoral veins. The etiology of venous sclerosis is unknown and users' perceptions of cause/meaning unexplored. This commentary stems from our hypothesis that venous sclerosis is causally related to heroin acidity, which varies by heroin source-form and preparation. We report pilot study data on first ever in vivo measurements of heroin pH and as well as qualitative data on users' concerns and perceptions regarding the caustic nature of heroin and its effects. Heroin pH testing in natural settings is feasible and a useful tool for further research. Our preliminary findings, for example, that different heroin source-forms and preparations have a two log difference in acidity, have potentially broad, vital and readily implementable harm reduction implications.

Going into the groin: Injection into the femoral vein among people who inject drugs in three urban areas of England

BACKGROUND

There have been increasing concerns about injection into the femoral vein - groin injecting - among people who inject drugs in a number of countries, though most studies have been small. The extent, reasons and harms associated with groin injecting are examined.

METHOD

Participants were recruited using respondent driven sampling (2006-2009). Weighted data was examined using bivariate analyses and logistic regression.

RESULTS

The mean age was 32 years; 25% were women (N=855). During the preceding 28 days, 94% had injected heroin and 13% shared needles/syringes. Overall, 53% reported ever groin injecting, with 9.8% first doing so at the same age as starting to inject. Common reasons given for groin injecting included: "Can't get a vein elsewhere" (68%); "It is discreet" (18%); and "It is quicker" (14%). During the preceding 28 days, 41% had groin injected, for 77% this was the only body area used (for these "It is discreet" was more frequently given as a reason). In the multivariable analysis, groin injection was associated with: swabbing injection sites; saving filters for reuse; and receiving opiate substitution therapy. It was less common among those injecting into two body areas, and when other people (rather than services) were the main source of needles. Groin injection was more common among those with hepatitis C and reporting ever having deep vein thrombosis or septicaemia.

CONCLUSIONS

Groin injection was common, often due to poor vascular access, but for some it was out of choice. Interventions are required to reduce injecting risk and this practice.

Correlates of Skin and Soft Tissue Infections in Injection Drug Users in a Syringe-Exchange Program in Malmö, Sweden

BACKGROUND

Injection drug users (IDUs) are at increased risk of various medical conditions, including bacterial skin and soft tissue infections (SSTIs). SSTIs, which are painful and can lead to life-threatening complications, are common but scarcely studied.

OBJECTIVES

To investigate life time, past 12 month and past 30-day prevalence for SSTI related to injection drug use, in IDUs at Malmö syringe exchange program (Malmö SEP). To investigate factors associated with having ever had an SSTI.

METHODS

IDUs were recruited from Malmö SEP (N = 80). They participated in a survey with questions about demographics, drug use, and experience of SSTIs. Factors independently associated with self-reported SSTI ever were assessed using logistic regression analysis.

RESULTS

The lifetime reported prevalence of SSTI was 58%, past 12 months 30%, and past 30 days 14%. Factors independently associated with SSTI ever were age (adjusted odds ratio [AOR] = 1.09; 95% confidence interval [CI] = 1.01-1.18), female sex (AOR = 6.75; 95% CI = 1.40-32.47), having ever injected prescribed drugs (AOR = 52.15; 95% CI = 5.17-525.67), and having ever injected in the neck (AOR = 8.08; 95% CI = 1.16-56.08).

CONCLUSIONS/IMPORTANCE

SSTI is common among IDUs in Malmö. Women and those injecting in the neck or injecting prescribed drugs (crushed tablets/liquids), are more likely to have had an SSTI.

Prevalence of skin problems and leg ulceration in a sample of young injecting drug users

Background

Drug users suffer harm from the injecting process, and clinical services are reporting increasing numbers presenting with skin-related problems such as abscesses and leg ulcers. Skin breakdown can lead to long-term health problems and increased service costs and is often the first indication of serious systemic ill health. The extent of skin problems in injecting drug users has not previously been quantified empirically, and there is a dearth of robust topical literature. Where skin problems have been reported, this is often without clear definition and generic terms such as ‘soft tissue infection’ are used which lack specificity. The aim of this study was to identify the range and extent of skin problems including leg ulceration in a sample of injecting drug users. Definitions of skin problems were developed and applied to descriptions from drug users to improve rigour.

Methods

Data were collected in needle exchanges and methadone clinics across Glasgow, Scotland, from both current and former drug injectors using face-to-face interviews.

Results

Two hundred participants were recruited, of which 74% (n = 148) were males and 26% (n = 52) were females. The age range was 21–44 years (mean 35 years). Just under two thirds (64%, n = 127) were currently injecting or had injected within the last 6 months, and 36% (n = 73) had previously injected and had not injected for more than 6 months.

Sixty per cent (n = 120) of the sample had experienced a skin problem, and the majority reported more than one problem. Most common were abscesses, lumps, track marks and leg ulcers. Fifteen per cent (n = 30) of all participants reported having had a leg ulcer.

Conclusions

This is an original empirical study which demonstrated unique findings of a high prevalence of skin disease (60%) and surprisingly high rates of leg ulceration (15%). Skin disease in injecting drug users is clearly widespread. Leg ulceration in particular is a chronic recurring condition that is costly to treat and has long-term implications for drug users and services caring for current or former injectors long after illicit drug use has ceased.

Groin injecting among a community-recruited sample of people who inject drugs in Thailand

Background

Use of the femoral vein for the injection of illicit drugs (i.e. groin injecting) has been linked to various health-related harms, including deep vein thrombosis. However, little is known about the prevalence of groin injecting and factors that predict this practice among people who inject drugs (PWID) in Thailand. We sought to investigate the prevalence and factors associated with groin injecting in Bangkok, Thailand.

Methods

Data were derived from the Mitsampan Community Research Project in Bangkok between July and October 2011. Multivariate logistic regression was used to identify factors associated with groin injecting in the last six months.

Results

Among 437 participants, 34.3% reported groin injecting in the last six months. In multivariate analyses, factors positively associated with groin injecting included: having higher than secondary education (adjusted odds ratio [AOR] = 1.59; 95% confidence interval [CI]: 1.00 – 2.56), weekly midazolam injection (AOR = 8.26; 95% CI: 5.04 – 14.06), and reports of having had drugs planted on oneself by police (AOR = 2.14; 95% CI: 1.37 – 3.36).

Conclusions

Over one-third of our sample of Thai PWID reported recent groin injecting. Frequent midazolam injection and higher education were found to be associated with groin injecting. That high intensity PWID were more likely to inject in the groin is concerning given the known negative consequences associated with the groin as a site of injection. Additionally, PWID who reported drug planting by police were more likely to inject in the groin, suggesting that reliance on law enforcement approaches may undermine safe injection practices in this setting. These findings highlight the need for evidence-based interventions to address the harms associated with groin injecting, including efforts to alert PWID to risks of groin injecting, the distribution of appropriate injecting equipment, and efforts to encourage use of other injecting sites.

One decade "narcotic addicted patients with deep vein thrombosis" in st. Alzahra hospital of isfahan, iran

BACKGROUND

Behavior and substance addiction is one of the risk factors for deep vein thrombosis (DVT). The aim of this study investigating the relationship between the different clinical manifestations pattern of DVT with the way, the amount and duration of narcotic drugs in patients admitted to St. Alzahra Hospital in Isfahan, Iran, during 10 years.

METHODS

In a cross-sectional study we studied all of the patients with DVT in St. Alzahra Hospital since 2003-2013 were studied.

FINDINGS

A total of 238 (59.1%) of the patients were male and 165 (40.9%) female. The mean age of men and women were 18.80 ± 48 and 19.60 ± 3.48 years old. The mean length of staying in the hospital was 5.40 ± 7.20 days. Addiction among patients with DVT was 19.1%. 28.2% of men suffered from DVT and 6% of the women were drug addicts (P < 0.001). Among the 77 patients taking the drug, 53.2% were heroin, 35.1%opium, and 11.7% used other injectable drugs. The results showed that 19 patients (28.6%) were taking the drug once daily, 27.3% twice a day, 6.5% three times a day, 15.6% once a week, and 26% taking the drug twice a week. From 403 patients, 2.2% had a problem in the upper limb, 44.4% in the left hand, and 55.6 in the right hand. The results showed that none of the 77 studied patients had involvement of upper limbs, but all of them in the lower limb. About 11.2% of studied patients were addicted to injective drugs. Also, 6% were addicted to non-injectable drugs and 2% to both injectable and non-injectable drugs.

CONCLUSION

DVT has many risk factors and addiction and intravenously (IV) drug abuse one of the most important for this illness and this problem mast be noticed by health worker and physicians.

Avascular necrosis of the femoral head due to the bilateral injection of heroin into the femoral vein: A case report

In this study, we report a case of avascular necrosis of the femoral head (ANFH) caused by the bilateral intravenous injection of heroin into the femoral vein. The patient had not used steroids, did not smoke and did not drink excessively. The patient did not present with any systemic diseases that may cause ANFH. ANFH often causes changes to the bone mass of the femoral head, particularly, the weight-bearing bone region. Imaging examination revealed that in addition to the bilateral hip joints, widespread changes to the bone mass existed in the peripheral area, where phlebitis and disseminated thrombosis had been caused by the injection of heroin. These results suggest that this ANFH case was related to the injection of heroin. This case is different from other cases of ANFH which have been caused by steroids and other factors, including smoking, alcohol intake and cytotoxic agents.

High rates of midazolam injection and associated harms in Bangkok, Thailand

AIMS

To identify the prevalence and correlates of midazolam injection among injecting drug users in Thailand.

DESIGN

Serial cross-sectional mixed-methods study.

SETTING

Bangkok, Thailand.

PARTICIPANTS

  A total of 435 adults who had injected drug(s) in the past 6 months were recruited through peer outreach and word of mouth in Bangkok in 2011.

MEASUREMENTS

Multivariable logistic regression was used to analyze self-reported data collected through an interviewer-administered survey in July-October 2011 (n = 435). Additionally, qualitative data were collected in June-July 2009 (n = 10) and analyzed to explore the health problems attributable to midazolam injection.

FINDINGS

Among 435 survey participants, the prevalence of daily midazolam injection in the past 6 months was 37.0% (95% confidence interval: 32-42). While 75.8% of the daily midazolam injectors identified heroin as their drug of choice, 91.8% of these individuals reported substituting heroin with midazolam when heroin was unavailable. In multivariable analyses, daily midazolam injection was associated with femoral vein injection [adjusted odds ratio (AOR) = 4.48], polydrug use (AOR = 4.94), daily heroin injection (AOR = 3.25), binge use (AOR = 1.75) and perceived increase in policing pressure (AOR = 1.95) (all P < 0.05). Qualitative accounts indicated severe health problems associated with midazolam injection, including nerve and vascular injuries.

CONCLUSION

Midazolam misuse is increasing among injecting drug users in Bangkok and appears to be used primarily as a substitute for heroin. Midazolam injection was associated independently with various risk factors for injection-related complications. Given the many deleterious effects of midazolam injection, novel interventions for midazolam injectors are needed urgently.

Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors

BACKGROUND

Users of illicit opioids are at increased risk of hospital admission for deep vein thromboses (DVTs); however, the community prevalence, risk factors, and complications of DVTs in this group are poorly understood.

AIM

This study aimed to describe the prevalence of previous DVT for users of opioids in primary care; provide age- and sex-adjusted annual incidence rates of DVT; and explore factors associated with DVT, concordance with subsequent treatment, and complications.

DESIGN

A retrospective analysis of DVT prevalence and incidence, and analysis of risk factors for DVT using Poisson regression of incidence rates.

METHOD

A review of 734 patients in treatment for opioid addiction, who were registered to a single, specialised primary care practice in Middlesbrough, England.

RESULTS

The prevalence of previous DVT in users of opioids was 13.9% (95% confidence interval [CI] = 11.5 to 16.6) with an annual incidence rate of 3.2% (95% CI = 2.6 to 3.7). The incidence rate increased with age and for female users; an exploration of risk factors suggests that rising age, female sex, sex-worker status, and intravenous delivery all independently increase the risk of DVT. Concordance with treatment appeared reasonable and, compared with DVT in groups of people who do not use drugs, there was no evidence of increased risk of pulmonary embolism. Participants with previous DVT reported lower health and wellbeing scores.

CONCLUSION

Primary care providers should be aware of the considerably increased risk of DVT and its sequelae in users of intravenous drugs. Evidence for effective primary care prevention and the effective management of DVT complications is lacking; until this emerges, vigilance on the part of clinicians may help to minimise harm.

Prevalence and characteristics of femoral injection among Seattle-area injection drug users

Injection drug use (IDU) into central veins, most common among long-term IDUs with no other options, can lead to severe infectious, vascular, and traumatic medical consequences. To follow-up on anecdotal reports of femoral vein injection and related medical problems in Seattle, we analyzed data from the annual survey of a community-based syringe exchange program. A total of 276 (81%) of 343 program attendees completed the survey in August 2010. Among 248 IDUs, 66% were male, 78% white, and 86% primarily injected opiates. One hundred respondents (40%) had injected into the femoral vein, 55% of whom were actively doing so, and 58% of whom reported medical complications that they attributed to the practice. Most (66%) used the femoral vein due to difficulty accessing other veins, although 61% reported other veins they could access and 67% reporting using other sites since initiating femoral injection. While injecting into muscle was more frequent among older IDUs with longer injection careers, the prevalence of femoral injection was highest among respondents in their late twenties with 2.5-6 years of injecting drugs. Multivariate analysis demonstrated an increased risk of initiating femoral injection each calendar year after 2007. Injecting into the femoral vein was also associated with white versus other race (odds ratio [OR] 2.7, 95% CI 1.3-5.4) and injection of primarily opiates versus other drugs (OR 6.3, 95% CI 1.2-32.9) and not associated with age, length of IDU career, or a history of injecting into muscle. These findings suggest a secular trend of increasing femoral injection among Seattle-area IDUs with a high rate of related medical problems. Interventions, such as education regarding the hazards of central venous injection and guidance on safe injection into peripheral veins, are needed to minimize the health consequences of femoral injection.

Injecting drug use via femoral vein puncture: preliminary findings of a point-of-care ultrasound service for opioid-dependent groin injectors in treatment

BACKGROUND

Within the UK, injecting in the femoral vein (FV), often called 'groin injecting', is a serious cause of risk and harm. This study aimed to use ultrasound scanning as a means to engage groin injectors (GIs), examine their femoral injecting sites and assess their venous health, with the intention of developing improved responses.

METHODS

Between September 2006 and March 2009, GIs attending a network of community drug treatment centres in South East England were invited to attend an ultrasound 'health-check' clinic. This paper provides a narrative account of the scanning procedure and operation of the service, with descriptive statistical analysis of GIs who attended. The analysis uses a structured, specially-developed clinical data set that incorporates a categorisation for the severity of FV damage. Case studies using ultrasound images and a link to a video are provided to illustrate the range of presentations encountered and the categorisations used for severity.

RESULTS

A total of 160 groin scans (76 bilateral and 8 unilateral) were performed in 84 GIs. The majority were men (69.0%) and the mean age of the sample was 36.8 years. The mean duration of drug use and injecting drug use was 19.7 years and 13.8 years, respectively. FV damage at the injecting site in the right groin was graded as minimal in 20 patients (25%), moderate in 27 (33.8%), severe in 16 (20.0%) and very-severe in 17 (21.3%). Corresponding figures for left FV were 24 (30.0%), 22 (27.5%), 18 (22.5%) and 16 (20.0%). Wide variation was observed in the time to the development of these grades of FV damage.

CONCLUSIONS

Modern, portable ultrasound scanners make it possible to examine the venous health of GIs in community treatment settings. Ultrasound scanning identified extensive FV damage, much hitherto-unrecognised in this population. These findings should further alert clinicians, policy-makers and patients to the urgent need for effective harm reduction responses to GI behaviour. Images of damaged FV in this paper might prove to be a useful resource for discussions about GI risks.

The needle and the damage done: clinical and behavioural markers of severe femoral vein damage among groin injectors

AIM

To identify factors associated with severe femoral vein (FV) damage among groin injectors (GIs) on oral opioid substitution treatment.

DESIGN

A cohort study.

SETTING

Drug treatment centres in South East England.

PARTICIPANTS

GIs attending an ultrasound 'health-check' clinic.

MEASURES

Femoral ultrasonography and clinical grading of venous disease in each leg.

METHOD

Comparison of 67 GIs with severely damaged FV and 86 GIs with minimal/moderate damage.

FINDINGS

The majority were men (69.3%) and the mean age was 36.2 years with mean duration of injecting drug use (IDU) of 13.3 years. There were no significant between-group differences in age, gender or duration of IDU. Severe FV damage was associated with longer duration of groin injecting (GI; P<0.005), use of thick needles (blue-hub, 23G; or green-hub, 21G; P<0.001), benzodiazepine injection (P<0.005), history of deep vein thrombosis (DVT, P<0.001) and recurrent DVT (P<0.001), presence of depressed groin scar (P<0.001) and chronic venous disease (CVD, P<0.001). Logistic regression analysis revealed needle size (β 1.2, Wald 4.9, P<0.05) and DVT (β 3.3, Wald 38.5, P<0.001) as the main predictors of severe FV damage.

CONCLUSION

Needle and syringe exchange services should consider only supplying appropriate lengths of orange-hub needle (25G) on request from GIs. Early cessation of GI, avoidance of benzodiazepine injection and prompt diagnosis and treatment of DVT might also reduce the prevalence of severe FV damage among GIs and the associated healthcare burden. Routine examination of injecting sites among these patients should include an assessment of severity of venous disease in each leg.

Complicated skin, skin structure and soft tissue infections - are we threatened by multi-resistant pathogens?

Tissue infections or skin, skin structure, and deep seated soft tissue infections are general terms for infections of the entire skin layer including the subcutaneous and muscle tissue layers and their respective fascia structures. Infections of the different mediastinal fascias (mediastinitis) and retroperitoneal fascia infections also belong to this category. Due to the variability of their clinical presentation, skin and soft tissue infections can be classified according to different features. The following aspects can be used for classification:

- anatomical structures

- pathogens

- necessity for urgent treatment

- extent of infection

The incidence of skin and soft tissue infections in which MRSA (methicillin-resistent Staphylococcus aureus) is involved has been steadily increasing over the past 15 years. These wounds should be treated according to the same open treatment principles as other infected wounds. Since these infections are often superficial contaminations, antibiotic therapy is not indicated. If systemic infection occurs in form of MRSA sepsis, antibiotic therapy is indicated.

Several recent reports identified MRSA as the leading pathogen in SSTIs. It also causes 20% to 50% of diabetes-associated foot infections in several countries and is associated with worse outcomes than other pathogens.

A nationwide, retrospective analysis of symptoms, comorbidities, medical care and autopsy findings in cases of fatal pulmonary embolism in younger patients

OBJECTIVE

Our objective was to provide a comprehensive description of fatal pulmonary embolism (PE) in younger persons. Specifically, we recorded information on symptoms, comorbidity, medical contact, if this had been required, and subsequent autopsy findings.

METHODS

We reviewed all death certificates from persons aged 0-35 years who had died between 1 January 2000 and 31 December 2006, and retrospectively identified all cases of fatal PE. Additional information was retrieved from the National Patient Registry, autopsy reports, and clinical charts.

RESULTS

Sixty-one cases of fatal PE were included; 38% of these were in males. The median age was 29 years. The predominant symptoms were dyspnea, syncope, leg pains, and chest pains. Sixty-three per cent of patients reportedly experienced symptoms for days, weeks, or months. More than half of the patients had sought medical care, and at the time of medical evaluation the majority of the patients were not hemodynamically compromised. In 21% cases, the correct diagnosis was reached before death; however, in only 5% of cases was this accomplished before clinical deterioration. Furthermore, clinical history and subsequent postmortem examinations showed that approximately half of younger persons dying from PE were otherwise healthy, and in no case was occult cancer diagnosed.

CONCLUSIONS

Our data show that a substantial proportion of younger victims of fatal PE had experienced symptoms for an extended period of time. Furthermore, the correct diagnosis remained elusive in the majority of cases, even though approximately half of the subjects had sought medical evaluation for symptoms that, in retrospect, were most likely caused by a venothrombotic event.

Is opium addiction a risk factor for deep vein thrombosis? A case-control study

The objective of the present study was to investigate the association between opioid addiction and deep vein thrombosis (DVT) and whether opioid addiction is a risk factor of DVT. This case-control study was conducted in Kerman, Iran in 2008. The cases were selected among the patients hospitalized because of DVT. The controls were recruited from the same hospital from internal wards. Opioid addiction was investigated by physician's interview based on Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria. Logistic regression modeling was carried out for statistical analysis. The crude odds ratio (OR) of opioid addiction for DVT was 4.25 (95% confidence interval = 2.6-6.9). However, multivariate logistic regression analysis revealed that opioid addiction was not an independent risk factor for DVT, OR 0.56 (0.1-3). The method of opioid usage--oral or inhaled and injected--OR 6.3 (1.41-28.3) and previous surgery in the last 3 months before the study, OR 3.1 (1.36-7), were significant independent risk factors for incidence of DVT. Opioid addiction per se was not a risk factor for DVT, whereas the method of its use especially injection was found to be independent risk factor for DVT. Our results suggested the prophylactic treatment of anticoagulant for intravenous drug abuser is considerable.

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

The data suggest 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 emphasize '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 emphasize 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.

Deep vein thrombosis among injecting drug users in Sheffield

AIMS

To identify the proportion of patients testing positive for deep vein thrombosis (DVT) who are injecting drug users (IDUs), and examine differences in the investigation and management of this group compared with non-IDUs.

METHODS

Analysis of data collected from emergency department records and a review of patient notes.

RESULTS

All patients in this study who were known to inject recreational drugs tested positive for DVT on Doppler ultrasound scan.

CONCLUSIONS

IDUs should be considered at high risk of developing DVT and should be investigated accordingly.

Portal and hepatic vein thrombosis in liver abscess: CT findings

OBJECTIVE

Our aim is to describe imaging findings of portal and hepatic vein thrombosis in pyogenic liver abscess on contrast-enhanced MDCT and to determine the incidence and evolving patterns on follow-up imaging.

METHODS

Over a 5-year period, 67 patients with liver abscess underwent single-phase (n=30) or triphasic (n=37) contrast-enhanced CT. Images were reviewed for the presence of portal vein (PV) or hepatic vein (HV) thrombosis, regional parenchymal attenuation, and changes on follow-up CT.

RESULTS

Venous thrombosis was seen in 28/67 patients (42%), involving PV in 16/67 (24%) and HV vein in 15/67 (22%); 3/67 (4%) had both PV and HV thrombosis. Thrombosis was seen as non-enhancing linear structures without expanding the lumen in all cases. Regional parenchymal attenuation during the portal-phase was hyperattenuating (10/16, 63%) or isoattenuating (6/16, 38%) in PV thrombosis, and mostly hypoattenuating (13/15, 87%) in HV thrombosis (P<.001). Of 27 patients with follow-up contrast-enhanced CT, venous thrombosis resolved in 10/27 (37%) within 6 months and persisted in 17/27 (63%) for 3-38 months, including 13 PV thrombosis and 4 HV thrombosis. Interval parenchymal atrophy was seen only in four all with persistent PV thrombosis.

CONCLUSIONS

Both PV and HV thrombosis frequently occurs in liver abscess and is seen as non-enhancing linear structures without expanding the lumen on contrast-enhanced CT. Regional attenuation changes in hepatic vein thrombosis were often hypoattenuating whereas none with portal vein thrombosis showed hypoattenuation.

Chronic Venous Insufficiency in HIV-Positive Persons with and without a History of Injection Drug Use

OBJECTIVE

To examine chronic venous insufficiency in human immunodeficiency virus-positive persons with and without a history of injection drug use and to examine the extent to which neuropathy further increased the risk of chronic venous insufficiency.

DESIGN

Cross-sectional stratified design with quota sampling.

SETTING

Infectious diseases clinic in a large, urban midwestern city.

PARTICIPANTS

Human immunodeficiency virus-positive persons, 27 with no history of injection drug use and 46 with a history of injection drug use, who met the inclusion criteria, including being 30 to 65 years of age, not pregnant, and willing to respond to a questionnaire and have their lower legs examined, were enrolled until the quota for each stratum (no injection drug use and injection drug use) was filled.

MAIN OUTCOME MEASURES

Chronic venous insufficiency clinical classification, injection drug use history, and presence of peripheral neuropathy.

MAIN RESULTS

Sixty-one percent of injection drug users (28/46) presented with severe chronic venous insufficiency compared with 11% (3/27) of noninjection drug users (P< .001). The presence of lower extremity neuropathy was not significantly related to chronic venous insufficiency classification.

CONCLUSIONS

This is the first study to report the high risk of chronic venous insufficiency in human immunodeficiency virus-infected persons who inject drugs. Chronic venous insufficiency should be assessed in human immunodeficiency virus-positive persons when there is a history of injection drug use, and measures to protect the legs should be implemented.

Hepatic Attenuation Differences Associated with Obstruction of the Portal or Hepatic Veins in Patients with Hepatic Abscess

OBJECTIVE

The purpose of our study was to determine the nature of the association between the attenuation difference of the hepatic parenchyma surrounding an abscess and obstruction of the regional portal vein or of the hepatic vein.

MATERIALS AND METHODS

Helical CT scans of 60 patients with hepatic abscess were analyzed for the presence of complete or partial obstruction of the portal or hepatic veins and for attenuation differences in the surrounding parenchyma. Clinical (age, sex, underlying disease, and microorganism) and CT (obstruction of the portal or hepatic vein and number, location, and size of abscesses) findings were analyzed statistically for possible associations with each of regional parenchymal hyper- and hypoattenuation by using the chi-square test and multivariate logistic regression analysis.

RESULTS

Regional parenchymal hyperattenuation was identified in 40 patients (67%). More patients with portal vein obstruction showed regional parenchymal hyperattenuation than patients without portal vein obstruction (22/27 patients vs 18/33, p = 0.028), and more patients with hepatic vein obstruction showed regional parenchymal hypoattenuation than those without hepatic vein obstruction (11/21 vs 3/39, p = 0.0003). Multivariate logistic regression analysis showed that portal venous obstruction was the only statistically significant predictor of regional parenchymal hyperattenuation (p = 0.032; odds ratio, 3.7) and that parenchymal hypoattenuation was associated with hepatic venous obstruction (p = 0.001; odds ratio, 44.9).

CONCLUSION

Parenchymal hypo- and hyperattenuation are frequently observed in the hepatic region surrounding an abscess on dynamic CT. Moreover, these parenchymal attenuation differences are associated with regional portal or hepatic vein obstruction.

Injection Drug Use and Wound Care

Persons who have injected drugs present challenges to providing wound care. They tend to have multiple physical and psychosocial problems and abuse many substances. They may mistrust health care providers because of past experiences and their perceived negative attitude toward providers. Because they often self-treat abscesses and wounds before seeking care, the infection or wound can be large. A complete history and physical examination should be obtained. All aspects of the person's background will have an impact on wound healing. Wounds need careful assessment and diagnosis. Correct diagnosis of the wound is critical for the proper treatment. Treatment decisions must also include pain control, financial concerns, living arrangements, insurance, and the person's ability to perform the care. Patient education is a critical link in enhancing positive wound healing outcomes.