Blood borne infections in sport: risks of transmission, methods of prevention, and recommendations for hepatitis B vaccination

Athletes are at risk of blood borne infections through bleeding injuries or injection of drugs with contaminated syringes. Prevention should focus on reducing non-sport associated risky behaviour, as well as dealing appropriately with bleeding injuries. The risk of transmission of hepatitis B virus is particularly high in athletes in contact and collision sports, those who live in or travel to endemic regions, injecting drug abusers, and those who practice first aid when there is no healthcare practitioner available. It is recommended that such athletes, and also adolescent athletes, should be vaccinated against the virus as a routine.     

Mortality following release from prison

We have studied deaths occurring after release from prison in the Canton of Geneva during the period 1982-86. The mortality rate during the first year after release was about 5 deaths/1000 person years, a rate over four times the age-adjusted rate in the general population. The majority of deaths were due to overdose by opiate drugs among young, frequently imprisoned drug abusers, and occurred within the first few weeks after release. Likely risk factors include loss of tolerance to opiates while in prison, and psychological and social stresses following release.     

Patterns of illicit drug use of prisoners in police custody in London, UK

AIMS AND METHODS: The aims of the study were to explore the current characteristics of drug misusers seen in police custody and identify trends or changes that have taken place in the last decade. A prospective, anonymised, structured questionnaire survey was undertaken of consenting consecutive, self-admitted illicit drug users seen by forensic physicians in police custody within the Metropolitan Police Service in London, UK in 2003. RESULTS: 30% of detainees were dependent on heroin or crack cocaine. Drug users (n=113) were studied in 2003. 95.4% completed the questionnaire. 82% were male, 18% female. Mean age was 28.5 y (range 18-49). 80% were unemployed; significant mental health issues (e.g., schizophrenia) were present in 18%; 15% had alcohol dependence; heroin was the most frequently used drug (93%); crack cocaine -- 87%; mean daily cost of drugs -- heroin GBP 76 (range 20-240), crack GBP 81 (range 20-300). >50% users inject crack and heroin simultaneously. 56% used the intravenous route; 25% had shared needles; 100% had accessible sources of clean needles; 6.4% were hepatitis B positive; 42% were aware of hepatitis prophylaxis; hepatitis C positive -- 20.2%; 3.6% were HIV positive. Mean length of time of drug use was 7.5 y (range 1 month -- 20 years); 82% had served a previous prison sentence; 54% had used drugs in prison; 11% had used needles in prison; 3% of users stated they had started using in prison. 38% had been on rehabilitation programs; 11% had been on Drug Treatment and Testing; Orders (DTTO); 32% had used the services of Drug Arrest Referral Teams in police stations; 10% were in contact with Drug Teams at the time of assessment. CONCLUSIONS: In the last decade, there appears to be a substantial increase in the prevalence of drug use in this population -- particularly of crack cocaine. Treatment interventions are either not readily available, or not followed through. In very general terms, the illicit drug use problem appears to have significantly worsened in the population seen in police custody in London, UK, in the last decade although there is evidence that health education and harm reduction messages appear to have had some positive effects.     

A controlled evaluation of assessments by doctors and nurses in a magistrates' court mental health assessment and diversion scheme

In this study, assessments of prisoners by doctors and nurses were compared in a provincial magistrates' court mental health assessment and diversion scheme, and outcomes were compared with the outcomes of those for whom no assessments were available during a control period. Substance misuse was relatively common and psychosis uncommon in the prisoners referred. Assessment by doctors enabled magistrates to reduce remands in custody of persons suspected of suffering from mental disorder and to grant bail in more cases. Only a small proportion of prisoners were admitted to hospital and although doctors and nurses recommended out-patient treatment in many cases, the attendance rate was low. Doctors were more likely than nurses to identify prisoners with medical needs that needed to be brought to the attention of the prison health care service, and to recommend out-patient psychiatric treatment and identify relevant medicolegal issues. Prisoners assessed by nurses were less likely than those assessed by doctors to attend alcohol or drug treatment services if recommended to do so. Prisoners who were admitted to hospital after a remand in custody spent longer on remand if assessed by nurses compared with those assessed by doctors.     

Bacteriological skin and subcutaneous infections in injecting heroin users-relevance for custody

Forensic medical examiners, custody nurses and police not infrequently come into physical contact with injecting heroin users whose injection sites maybe infected. Karch evaluated published reports on bacteriological findings at infected injection sites in drug users in 1996. Studies were then 10 years out of date. Recent concern has been about unexplained deaths in injecting heroin users, partly attributed to toxins produced by Clostridium novyii, Clostridium perfringens (welchii) and Clostridium botulinum. In response to this epidemic Lambeth, Southwark and Lewisham Health Authority (London, UK) urged investigation and treatment of injection site infection in heroin users within their area; circularising police stations and general practices with an official notice. In response, I followed up and treated in general practice 35 injecting heroin users with injection site infection presenting as detainees at two South London police stations. All swabs taken had a 48 hour incubation for anaerobic bacteria. At audit, no spore forming anaerobes were found. Just under 25% had non spore forming anaerobes such as bacteroides. Just over 50% had staphylococci in the injection site infection. Just under 20% had streptococci, half of which were beta haemolytic, a possible contact risk of infection being erysipelas, cellulitis, impetigo or conjunctivitis. No comparable studies were found but a study in New York in 1984 tabulated bacteriological findings of soft tissue infections in 29 hospitalised parenteral drug users. They found similar proportions of staphylococci, far more with streptococci, hardly any with non spore forming anaerobes and one case of spore forming anaerobic clostridium perfringens.     

Imaging correctional facility patients

More than 2.2 million people are incarcerated in the United States, and thousands of these men and women will be brought to medical facilities at some point during their arrest or incarceration. Radiologic technologists across the country conduct imaging procedures for correctional facility patients. Some technologists work within prison infirmaries or in mobile units parked on prison grounds. Others work in hospitals that have contracts with penitentiaries. Whether inside or outside prison walls, imaging of correctional patients requires awareness. This Directed Reading describes the prison environment in the United States, the most common diseases that prisoners have, special prison populations and safety measures for performing imaging procedures on patients in the custody of prison officials.     

Abscess related to anabolic-androgenic steroid injection

One million individuals in the United States, predominantly males under 25 yr of age, are current or past users of anabolic-androgenic steroids. Fifty percent of these young adults administer their drugs intramuscularly, placing them at risk for infections related to injection. We present here a case report of an injection-related thigh abscess in a 26-yr-old anabolic steroid injector who did not use sterile injection technique and reported sharing multidosage vials with two other weightlifting colleagues. Reported infections associated with anabolic-androgenic steroid injection include abscesses attributable to Mycobacterium smegmatis, Staphylococcus, Streptococcus, and Pseudomonas organisms as well as HIV, hepatitis B, and hepatitis C. These infections are primarily related to nonsterile injection technique, shared injection equipment, and are avoidable with appropriate prevention techniques. Education is needed to prevent infectious complications such as abscesses and blood-borne pathogens among anabolic-androgenic steroid injectors.     

Medical examination of fitness for police custody in two large German towns

Worldwide, there is a high risk of medical complications or death in police custody. This risk is often increased by unclear legislation, a lack of clearly defined responsibility and medical examination standards. Any solution to these problems requires as a very basis the systematic analysis of the medical examinations that determine whether a person is fit to be detained in custody. We analysed a total of 3,674 medical records on fitness for custody, taken from two large German towns (Halle/S and Bremen). The examined individuals were predominantly males or of a younger age. The indication in the majority of cases was acute alcoholic intoxication or drug withdrawal syndromes. Traumata and internal or mental diseases were also quite frequent. For approximately 50% of all cases, fitness for custody was declared on certain conditions. Only 39.8% were found to be unconditionally fit for detention in custody. In just under 10% of the cases, the person was found unfit for custody. These cases concerned mainly persons with psychological symptoms and advanced alcohol or drug withdrawal syndromes. We were able to show that the recent introduction of new police custody regulations in Halle/S had a significant influence on the medical decision on fitness for custody. Our detailed assessment has provided us with the basis to develop solutions for the improvement of medical care in police custody. The focus lies here on the organisation and legal regulation of the medical aspects of custody but also on policing and medical work.     

A clean bill of health? The efficacy of an NHS commissioned outsourced police custody healthcare service

Police custody healthcare services for detainees in the UK are most commonly outsourced to independent healthcare providers who employ custody nurses and forensic physicians to deliver forensic healthcare services. A pilot was introduced in 2008 by the Department of Health to explore the efficacy of commissioning custody healthcare via the NHS, in the wake of the 2005–2006 shift of prison healthcare to the NHS. The objective was to improve quality and accountability through NHS commissioning and the introduction of NHS governance to the management and delivery of custody healthcare. This article discusses key themes that arose from the project evaluation, which focused on the commissioning relationship between the police, the NHS commissioner and the private healthcare provider. The evaluation observed an evolving relationship between the police, the local NHS and the front-line nurses, which was complicated by the quite distinctive professional values and ideologies operating, with their contrasting organisational imperatives and discordant values and principles. A key challenge for commissioners is to develop synergy between operational and strategically located stakeholders so that they can work effectively towards common goals. Government policy appears to remain focused on creating safe, supportive and humane custody environments that balance criminal justice and health imperatives and support the rights and needs of detainees, victims, professionals and the public. This remains an ambitious agenda and presents a major challenge for new criminal justice health partnerships.     

海洛因依赖者吸毒方式与HIV及HBV、HDV、HCV、HGV感染关系研究

调查152例海洛因依赖者吸毒方式及HIV、肝炎病毒感染情况。结果显示:吸毒者中存在HIV感染。HBVM、HBsAg、HDVM、HCV、HGV感染率分别为69.74％、19.74％、2.63％、45.39％、35.53％。静脉吸毒与非静脉吸毒相比,除HBVM、HBsAg感染率无显著性差异外,其它均有显著性差异。研究认为吸毒者是4种肝炎病毒感染的高危人群,静脉吸毒方式对HCV、HGV感染较HBV感染影响更大,提示HGV感染在易感性及传播途径上与HCV更相似,而与HBV不完全相同。     

Custody suicide with washrag: A case report with clinical and custodial consideration

Custody or prison suicides with a washrag are rather unusual and few case reports present in the forensic literature. Completed suicide by using a washrag without the awareness of custody supervisors and medical staff ought to draw attention to related personnel. We report a case of suicide where the victim was a suspect with criminal cases, who had been put behind bars in local custody. However, the next day the man was found in an unconscious state and scant of breath. After admission and first-aid treatment, the victim was pronounced dead. Significantly, a half-piece of washrag was found blocked in his laryngeal cavity, inosculating with another piece concealed in his underpants. The psychological condition of criminal offenders is extremely complicated and varies with each individual. Effective administration and moderate counseling are not mutually exclusive with each other and both should afford the criminals a sense of calmness to face consequences.     

海洛因依赖者巨细胞病毒感染的研究

调查了 15 2例海洛因依赖者吸毒方式及巨细胞病毒 (CMV)感染情况 ,结果显示 :CMV总感染率为 15 79% ,静脉吸毒者与非静脉吸毒者相比 ,感染率无显著性差异 (P >0 0 5 )。研究认为尽管吸毒者是CMV感染的高危人群 ,静脉吸毒以及注射器不消毒或与他人共用注射器、稀释毒品溶剂不消毒等不是造成CMV感染的主要原因 ,而吸毒引起机体免疫力低下可能是巨细胞病毒感染的主要危险因素。     

The sexual habits of males who molest

To gain better understanding into the causes of molesting behaviour in males, we examined a prison cohort of molesters and compared them with a control group comprising thieves. The molesters were older, had attained a higher educational level and were more likely to be married. They had their initial sexual intercourse at an older age but tended to have multiple sexual relationships and were less likely to report having viewed pornographic material. Three months prior to committing their offences, molesters seemed to engage in less sexual activity. The implications are that molesters had a need for more explicit sexual contact but were unable to sustain ongoing, stable, intimate sexual relationships.     

Todesfälle im Gewahrsam

A total of 86 autopsy cases of death in imprisonment have been analyzed of which 66 occurred in prison and 20 during parole. The deaths in prison were mainly due to suicide or drugs, while those on parole occurred because of intoxication with more than one substance. Means to decrease drug-related mortality are discussed. Furthermore, we report four cases of death in police custody.     

Drug concealment in custody deaths--two cases

Internal concealment of drugs of abuse is a well established method of transporting such substances to avoid detection while they are being smuggled across international frontier lines.(1,2) The same method has been used by dealers and 'pushers' in between purchases on their selling rounds to avoid detection by the police. These methods of hiding drugs may be used by persons taken into short-term custody, in their belief that potential withdrawal effects would thus be avoided by continued availability of their drugs. Two cases are reported in which such concealment was discovered at autopsy after death had occurred while in police custody. In one case the drug concealed was dihydrocodeine and was directly responsible for the death.     

A study of outrage of modesty offenders in a Singapore prison

Outrage of modesty (OOM) offenders cause considerable annoyance and distress to their victims. The offending behaviours include touching, grabbing or fondling of erogenous or non-erogenous parts of the victim's body. The purpose of this study is to examine a prison cohort of OOM offenders and to compare them with a group of OOM offenders who had been remanded in a state mental hospital. All prisoners serving sentence over a two-year study period were interviewed. They were of similar mean age to the hospital cohort but were better educated, more likely to be married and most were working. Victims tended to be young females with an average age of 19 years. Psychotic disorders were rarely present, although 15% had a dissocial personality disorder. Those with previous OOM convictions were likely to have had past psychiatric consultations and were more likely to be unmarried. However, there were no statistically significant differences between convicted first-time offenders and repeat offenders with respect to age, educational level, nature of offences and alcohol consumption. The prisoners were less inclined to commit their offences in the mornings. Breasts and genitalia were the favoured targets for molest action, irrespective of time or place or whether the offence was committed by a first or repeat offender. The offences were often committed along staircases, corridors and in crowded public places.     

11239例海洛因依赖者HIV感染的临床检测

目的 了解海洛因依赖HIV感染的原因,为控制HIV蔓延提供依据。方法 对11239例海洛因依赖进行HIV血清抗体检测,并对阳性的吸毒方式进行调查。结果 HIV血清学检测抗体阳性反应36例,全部为静脉注射毒品滥用,有共用注射器具史和性乱史。结论 静脉注射毒品已成为我国目前艾滋病传播的最主要的途径,海洛因依赖为艾滋病高发人群。建议(1)加强对高危人群预防艾滋病的宣传教育;(2)对高危行为进行干预;(3)加强对海洛因依赖的血清学检测。以控制HIV流行。     

Assessment in police custody of individuals under the influence of alcohol with co-morbid psychiatric disorders

Individuals with a diagnosis of excessive alcohol intake are commonly encountered in police custody. These individuals have a high incidence of co-morbid psychiatric disorders. The Epidemiological Catchment Area (ECA) Study reported that 37% of alcoholics have a co-morbid mental disorder.(1)It is, therefore, important that individuals in custody who have a history of excessive alcohol intake are adequately assessed, in order to identify such co-morbid disorders so that appropriate management is implemented. Assessment of all individuals in police custody should include: To date, little has been written on how such assessments should be carried out in police custody. This paper discusses the presentation of psychiatric disorders in individuals with a history of excessive alcohol intake and suggests how they should be assessed in custody. A subsequent issue of the journal will include an article discussing the management of such individuals.     

The mental health needs of people with a learning disability detained in police custody

Few research studies examine the prevalence or mental health needs of people with a Learning Disability (LD) detained in police custody. This paper describes the population of detainees with an LD who presented to an inner city inter-agency police liaison service during a three-year period. Two forensically trained Community Mental Health Nurses (CMHNs) screened all custody record forms (n=9014) for evidence of a mental health problem or LD. The CMHNs interviewed positively screened detainees (n=1089) using a battery of measures designed to assess mental health status, risk-related behaviour and alcohol or drug abuse. Almost one-in-ten of those interviewed (95/1089) were judged to have a possible or definite LD. Fifty-two per cent were cases on the General Health Questionnaire (GHQ) whilst 61% attained 'above threshold' Brief Psychiatric Rating Scale (BPRS) scores. The majority (63%) had a history of causing harm to others while 56 per cent had a history of self-harm. More than half (56%) regularly consumed harmful levels of alcohol while one-in-four (27%) reported abusing drugs. Higher than expected numbers of detainees have a learning disability and most have complex mental health needs. A police liaison service offers a way of identifying people with LD and connecting them with appropriate health and social care agencies.