The purpose of this thesis was to examine hand actions required of nurses and pharmacy assistants involved with chemotherapy drug administration over a work shift, and propose associated risk control strategies. There is a need to evaluate and redesign manual “pushing” and mixing of chemotherapy drugs to prevent musculoskeletal disorders and associated healthcare costs. Muscle activity of the forearm flexor and extensor muscles, and thumb forces, were measured from 5 lab nurses, 5 floor nurses and 5 pharmacy assistants who had their actions recorded throughout their shift. Lab nurses performed an average of 1.85 ± 0.48 hand efforts per min, floor nurses performed 1.62 ± 0.09 per min, while pharmacy assistants performed 5.29 ± 1.27 per min. Syringe use accounted for 17% of the pharmacy assistants’ shift and 12% each for the floor and lab nurses. The tasks of drawing fluid and manually pushing treatment represented 10% of the work day. The left forearm flexors generated the highest activity over the workday and across tasks while only resting for 6% of the workday. The high number of hand efforts, combined with prolonged durations, and lack of muscular rest show evidence of muscular overload over the course of the shift as well as illustrate that the pharmacy assistants are at higher risk for WMSD. The results may also help explain the documented injury statistics and complaints associated with the arm, hand and thumb and support the implementation of a chemotherapy robot to reduce the risk associated with tasks performed by the pharmacy assistants. Further, the findings of this thesis can act as a guide for future evaluation and research of workplaces with similar syringe and hand demands. The risk reducing strategies presented may also be applied to other jobs where hand and syringe use is repetitive and prolonged. / Thesis / Master of Science (MSc)

The aim of this thesis is to describe the users visiting the syringe exchange clinic in Malmö with respect to what characterises the group, how they utilize the services of the clinic and how their patterns of participation relate to risk behaviour, physical and mental health and social development. The heterogeneity of the group has been captured by the use of Stimsons dimensions “integration in majority society” and “involvement in sub-culture”, yielding four different groups of syringe exchangers: “stables”, “loners”, “two-worlders” and “junkies”. The study rests on two sources of data: a register from the clinic including all syringe exchangers that have visited the clinic between 1989 and 2003, altogether 3660 individuals, and an interview of visitors at the clinic during 1995, including 496 persons. The results show that syringe exchangers, compared to other persons with severe addiction in Malmö, to a larger extent use amphetamine as their drug-of-choice, are older and inject more irregularly. The population visiting the clinic is heterogeneous with respect to integration in society and involvement in sub-cultures. The group classified as junkies do, as expected, display the highest inclination to share syringes and needles with other and hence have the most advanced risk behaviours. As to utilization of the programme, the results show that the longer the syringe exchangers stay in the programme, the more frequent they visit it. Also with respect to utilization-patterns, we find substantial variations within the studied group. Five categories are discernible: drop-in visitors with only one or two visits, sporadic visitors who in spite of contacts over a number of years never really establish a regular contact, intermittent visitors who have had contact over several years but display a very irregular visiting pattern, regular visitors who relatively fast establish a consistent contact with visits between uniform time intervals and frequent visitors who tend to stay longer than others and visit the clinic more often. Another aspect of utilization is to what extent the distribution of needles and syringes cover the needs of the visitors. With a strict definition of need, only a minority manages to cover their needs, but if we accept a more extensive individual re-use, around 90 percent of the average need is covered. Data also reveals that a very high proportion of the users on at least one occasion have visited the programme without syringe exchange taking place or any complementary service delivered. Basically these visits seem to be of a more social nature, reinforcing the contacts between the staff and the visitors. Data do not give any clear support for the basic assumption that syringe exchange reduce the incidence of HIV or hepatitis. Recent sharing of utensils or low coverage of syringe need through the programme do not predict a higher infection risk. Instead we find that the social contacts with the staff (without syringe exchange) function as a predictor of lower incidence. This indicates that the mechanisms may be more complex than just related to the provision of clean needles and syringes. The result shows that integration increase over time while sub-cultural involvement decreases. However, the patterns for different groups are very diverse and we find no evidence that more frequent contacts as such are related to increased integration. There is however, some evidence that social visits are positively related to increased integration. No support could be found for the assumption that the programme increases the number of severe addicts.

The improvement of blood cell sorting techniques in recent years have attracted the attention of many researchers due to the possible benefits that these methods can lead in biology, regenerative medicine, materials science and therapeutic area. In this work a cell sorting technique based on filtration is described. The separation occurs by means of a microfluidic device, suitably designed, manufactured and tested, that is connected to an external experimental set-up. The fabrication process can be divided in two parts: at first it is described the manufacturing process of a filtering membrane, with holes of specific size that allow the passage of only certain cell types. Following the microfluidic device is fabricated through the mechanical micromilling. The membrane and the microdevice are suitably bonded and tested by means of an external connection with syringe pumps that inject blood samples at specific flow rates. The device is designed to separate blood cells and tumor cells only by using differences in size and shape. In particular during the first experiments red blood cells and platelets are sorted from white blood cells; in the other experiments red blood cells and platelets are separated from white blood cells and tumor cells. The microdevice has proven to be very efficient, in fact a capture efficiency of 99% is achieved. For this reason it could be used in identification and isolation of circulating tumor cells, a very rare cancer cell type whose presence in the bloodstream could be symptom of future solid tumor formation. The various experiments have also demonstrated that tumor cells survive even after the separation treatment, and then the suffered stress during the sorting process does not harm the biological sample.

The use of solid dispersions to formulate poorly water soluble drugs is a growing field in the pharmaceutical sciences. Hot-melt extrusion is a common method for producing dispersions. However, bench-top extruders require large amounts of powder to run and are inappropriate for early formulation screens. Plastic and glass syringes are readily available in most laboratories. 250 mg of drug-polymer blend is placed in a plastic syringe body that has the tip covered with a bent needle. The syringe is heated for 5 minutes and the extrudate is pushed through the syringe. Extrudates are characterized by differential scanning calorimetry and powder x-ray diffraction. Acetaminophen, griseofulvin, indomethacin, salicylamide, and sulfamethoxazole extruded with polyvinylpyrrolidone K12 match or exceed the performance of solvent evaporated controls. Glass syringes can be used when polymers have processing ranges above the melting point of the plastic syringes. Syringe extrusion is effectively demonstrated as a rapid process for early formulation screening.

Since 2010, the incidence of acute Hepatitis C Virus (HCV) infections in the U.S. has nearly quadrupled. Re-use and sharing of syringes among people who inject drugs (PWID) is a significant contributor to increased rates of HCV transmission and a risk factor for HIV infection. Community pharmacists are uniquely positioned to offer harm reduction services that lower the transmission of HCV/HIV by providing sterile syringes to PWID. However, legislation on non-prescription syringe dispensing varies by state and differences in individual pharmacists’ interpretation and attitudes regarding these laws may impact their willingness to participate in harm reduction services. Little is known about the impact of these factors on pharmacist engagement with harm reduction services in central Appalachia, a region particularly hard-hit by the opioid epidemic. The objective of this project is to qualitatively evaluate open-ended responses collected as part of a survey administered to community pharmacists in three central Appalachian states in order to determine: 1) pharmacists’ knowledge and attitudes regarding their state’s non-prescription syringe dispensing laws; and 2) the correlation of attitudes about state legislation to pharmacists’ intent to sell syringes to PWID. A telephonic community pharmacist survey on non-prescription syringe attitudes and behaviors was conducted between April and June 2018 in Northeast Tennessee, Western North Carolina, and Southwest Virginia. Survey responses were obtained from pharmacists practicing in 391 community pharmacies (51% response rate) in the study region. Transcribed responses to open-ended survey questions were extracted from the dataset and a qualitative analysis was completed using a generalized inductive approach. A single investigator coded all qualitative data and a second investigator coded data from a random selection of 10% of the respondents in order to develop themes through consensus. Descriptive analysis was conducted using SPSS version 25 to compare syringe law attitude thematic categories to respondents’ intent to sell syringes to PWID. Preliminary analysis identified discrepancies in pharmacists’ non-prescription syringe law knowledge, state-specific differences in pharmacists’ non-prescription syringe law attitudes, and underlying differences in willingness to sell syringes to PWID based on attitudes. The findings may encourage pharmacists to reflect on personal attitudes and interpretation of state-specific legislation as factors that may influence participation in an evidence-based harm reduction strategy for prevention of HCV/HIV transmission. This study offers preliminary results that will serve as a basis for larger studies and interventions aimed at reducing ambiguity in pharmacists’ interpretation of non-prescription syringe dispensing laws and encouraging pharmacists to counter the spread of HCV/HIV in an evidence-based manner.

Indiana University-Purdue University Indianapolis (IUPUI)

No / Angiography is an important minimally invasive diagnostic procedure in endovascular interventions. Effective training for the procedure is expensive, time consuming and resource demanding. Realistic simulation has become a viable solution to addressing such challenges. However, much of previous work has been focused on software issues. In this paper, we present a novel hardware system-an interactive syringe device with haptics as an add-on hardware component to 3D VR angiography training simulator. Connected to a realistic 3D computer simulation environment, the hardware component provides injection haptic feedback effects for medical training. First, we present the design of corresponding novel electronic units consisting of many design modules. Second, we describe a curve fitting method to estimate injection dosage and injection speed of the contrast media based on voltage variation between the potentiometer to increase the realism of the simulated training. A stepper motor control method is developed to imitate the coronary pressure for force feedback of syringe. Experimental results show that the validity and feasibility of the new haptic syringe device for achieving good diffusion effects of contrast media in the simulation system. A user study experiment with medical doctors to assess the efficacy and realism of proposed simulator shows good outcomes. / National Natural Science Foundation of China (61402278), the Innovation Program of the Science and Technology Commission of Shanghai Municipality of China (16511101302), Research Program of Shanghai Engineering Research Center of Motion Picture Special Effects (16dz2251300)

Background: Rural people who inject drugs (PWID) have been disproportionately affected by the ongoing hepatitis C virus (HCV) epidemic. Methods: Using data from a cross-sectional study of PWID from rural New Hampshire, Vermont, and Massachusetts, we evaluated the potential for syringe services programs (SSPs) to lower the risk of HCV infection among rural PWID via their influence on the physical and social environment. The specific aims were to evaluate: 1) the association of spatial proximity to the nearest SSP with HCV seroprevalence and injection risk behaviors; 2) the association of indirect SSP use (secondary syringe exchange) with HCV seroprevalence and injection risk behaviors; and to 3) explore PWIDs’ perceptions and experiences with obtaining injection supplies, injection risk behaviors, and HCV. Results: Living farther from an SSP was associated with a higher prevalence of HCV seropositivity and injection risk behaviors. Indirect SSP use was weakly and imprecisely associated with lower prevalence of injection risk behaviors, while direct SSP and pharmacy use were both associated with a higher prevalence of HCV seropositivity and injection risk behaviors. Participants described sharing syringes in response to limited access to syringe sources. Syringe sharing behavior was influenced by perceptions of HCV risk, HCV status, and emotions of trust and intimacy. Conclusion: Spatial proximity to an SSP and direct use of an SSP may lower the risk of HCV infection among rural PWID. HCV prevention efforts in rural New England need to address syringe access and cultivate the perception that HCV is a serious but preventable risk.

Society's view of addiction problems and their treatment is constantly evolving. This study highlights the experience of counselors, nurses and others with social worker education of the structure of the activities, the practical work and the social work in a medical context. Based on previous research and theoretical concepts, this qualitative study is conducted to gain a more in-depth insight into the practical work of the professions and to create an understanding of the structure of the organization. The reason for conducting this study is also to see similarities and differences in how the employees of the syringe exchange activities experience what social work looks like in a medically permeated workplace. To obtain the empirical data, semi-structured interviews were conducted with seven different active professions at different needle exchange facilities in Sweden. The results of the study highlight, among other things, the professions' flexibility and broad scope of action, the importance of collegial collaboration for knowledge exchange and support, and the laws and regulations that the activities need to relate to. Conclusions that could be drawn were that the social work at the syringe exchange facilities is also a pervasive part of the work of the professionals and the interventions offered. Similarly, laws and regulations are perceived to be somewhat flexible according to the interviewees and many times solutions are found to ensure the best interests of the patient. Another conclusion is that large parts of the professionals' experiences of the activities support the goal and purpose of the syringe exchange activities in Sweden, i.e. to motivate people to receive care and treatment.

Studien undersöker förekomsten av brukarinflytande vid implementeringen av det första sprututbytet i Stockholms län. I studien ges en bakgrund till Sveriges narkotikapolitik och hur dess utvecklingen har sett ut från 70- talet fram till idag. I bakgrunden till studien presenteras ett governace-perspektiv på brukarinflytande och de deliberativa processer där brukarinflytande är en naturlig del av policyprocessen. Syftet med studien är undersöka förekomsten av brukarinflytande i implementeringsdelen av den besluts- policyprocess som ledde fram till sprututbytets öppnande i april 2013. Studiens teoretisk ramverk består av teorier som ifrågasätter givenheten i governance-synsättet på brukarinflytande genom hänvisning till svårigheter med aktörskap och risken med konstruerat brukarinflytande. Forskningsstrategin som studien utgår ifrån är intervjuer med utvalda respondenter som har varit delaktiga vid implementeringen av sprututbytet samt brukarorganisationer som representerar och företräder sprututbytets målgrupp. Resultatet av studien visar på en svag förekomst av brukarinflytande vid implementeringen av sprututbytet. Det brukarinflytande som kan anses har förekommit har varit på en individuell nivå och icke-formaliserat. I analysen presenteras tre möjlig förklaringar till den svaga förekomsten av brukarinflytande vid implementeringen av sprututbytet samt en analys om svårigheter med aktörskap vid implementeringen kopplat till studiens teoretiska ramverk. / This study examines the occurrence of user influence during the implementation of the first Needle and Syringe exchange Programme (NSP) in Stockholm County. The survey in his study consists of interviews conducted with persons that have been involved during the process and debate around the NSP in Stockholm County. The interviews have been conducted with two different groups of actors: User organizations and public actors. The first group called user organizations consists of actors from three different user organizations representing and organizing the target group for the NSP. The second group called public actors consists of public actors which have been involved under and/or before the implementation of the NSP in Stockholm County. The study contains a description of the background of NSPs in Sweden. The study describes the development of the Swedish drug policy from 1970 until today. Further it covers the development of the NSPs in other parts of Sweden as well as the development of harm reduction as a general strategy for drug addiction management. Several definitions to the terms user and user influence are presented. Four are conventional definitions of the term user, together with a fifth one which is then used within in the context of the study. The study presents definitions of the term user influence by a model dividing user influence in three categories: individual level, operational level and system level. Another division of the term user influence presented is formalized and non-formalized user influence. These different classifications are used in the analysis of the results. The study also presents a background to the governance view on user influence as a natural and unproblematic part in the policy process. The theoretical framework in the study consists of two parts: The first part questions governance and the given of user influence within a policy process. The study highlights the problems with a governance view on actorhood and user influence. The second part of the theory chapter presents a model for the policy process. The policy process is described in five stages: Initiation, processing, decision making, implementation and evaluation. The results of the survey show little occurrence of user influence during the implementation of the NSP. By using the classification with the three different levels of user influence the result is that the occurrence of user influence found in the investigation has the characteristics of individual level user influence. The study also shows that the user influence found can be classified as non-formalised influence. The analysis first discusses the factors of why there has been little occurrence of user influence during the implementation of the NSP and proposes three different plausible explanations: Politically sensitive question, structural difficulties and users view was already known. The analysis also discuss the problem with a governance view on actorhood and user influence in relation to the study. The study concludes that there has been little occurrence of user influence during the implementation of the NSP in Stockholm County and that the occurrence of user influence found can be classified as individual level user influence, with one plausible exception.