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This study aimed to report the real-world atrial fibrillation (AF) diagnostic yield of the implantable cardiac monitor (ICM) in patients with stroke or transient ischemic attack (TIA), and compare it to patients with an ICM for unexplained syncope.We used patient data from device clinics across the United States of America with ICM remote monitoring via PaceMate™, implanted for stroke or TIA, and unexplained syncope. Patients with known AF or atrial flutter were excluded. The outcome was AF lasting ≥2 min, adjudicated by International Board of Heart Rhythm Examiners certified cardiac device specialists.We included a total of 2469 patients, 51.1% with stroke or TIA (mean age: 69.7 [SD: 12.2] years, 41.1% female) and 48.9% with syncope (mean age: 67.0 [SD: 17.1] years, 59.4% female). The cumulative AF detection rate in patients with stroke or TIA was 5.5%, 8.9%, and 14.0% at 12, 24, and 36 months, respectively. The median episode duration was 73 (interquartile range: 10-456) min, ranging from 2 min to 40.9 days, with 52.3%, 28.6%, and 4.4% of episodes lasting at least 1, 6, and 24 h, respectively. AF detection was increased by age (adjusted hazard ratio [for every 1-year increase]: 1.024, 95% confidence interval: 1.008-1.040; p = .003), but was not influenced by sex (p = .089). For comparison, the cumulative detection rate at 12, 24, and 36 months were, respectively, 2.4%, 5.2%, and 7.4% in patients with syncope.Patients with stroke or TIA have a higher rate of AF detection. However, this real-world study shows significantly lower AF detection rates than what has been previously reported.

Aims This study aimed to investigate the impact of sex on the clinical profile, utilization of rhythm control therapies, cost of hospitalization, length of stay, and in-hospital mortality in patients admitted for atrial fibrillation (AF) in the United States. Methods and results We used data from the Nationwide Inpatient Sample for the year 2018. Regression analysis was performed to investigate differences between men and women. A P-value ≤ 0.05 was considered significant. We included 82592 patients with a primary diagnosis of of AF 50.8% women. Women were significantly older (mean age 74 vs. 67 years, P Conclusion There were differences in the risk profile, management, and outcomes between men and women hospitalized for AF. Further studies are needed to explore why women are treated differently regarding rhythm control procedures.

Inspired by Locard's exchange principle, which states "every contact leaves a trace", a trace residue sampling strategy has been developed for the analysis of discarded drug packaging samples (DPS), as part of an early warning system for illicit drug use at large public events including music/dance festivals. Using direct analysis in real time/mass spectrometry and tandem mass spectrometry, rapid and high-throughput identification and characterization of a wide range of illicit drugs and adulterant substances was achieved, including in complex polydrug mixtures and at low relative ion abundances. A total of 1362 DPS were analyzed either off-site using laboratory-based instrumentation or on-site and in close to real time using a transportable mass spectrometer housed within a mobile analytical laboratory, with each analysis requiring less than 1 min per sample. Of the DPS analyzed, 92.2% yielded positive results for at least one of 15 different drugs and/or adulterants, including cocaine, MDMA, and ketamine, as well as numerous novel psychoactive substances (NPS). Also, 52.6% of positive DPS were found to contain polydrug mixtures, and a total of 42 different drug and polydrug combinations were observed throughout the study. For analyses performed on-site, reports to key stakeholders including event organizers, first aid and medical personnel, and peer-based harm reduction workers could be provided in as little as 5 min after sample collection. Following risk assessment of the potential harms associated with their use, drug advisories or alerts were then disseminated to event staff and patrons and subsequently to the general public when substances with particularly toxic properties were identified.

Aims The aim of this study is to summarize data from prospective cohort studies on clinical predictors of stroke and systemic embolism in anticoagulant-naïve atrial fibrillation (AF) patients. Methods and results EMBASE, MEDLINE, Global Index Medicus, and Web of Science were searched to identify all studies published by 28 November 2019. Forty-seven studies reporting data from 1 756 984 participants in 15 countries were included. The pooled incidence of stroke in anticoagulant-naïve AF patients was 23.8 per 1000 person-years (95% CI 19.7–28.2). Older age was associated with incident stroke or systemic embolism, with a pooled hazard ratio (HR) of 2.14 (95% CI 1.85–2.47), 2.83 (95% CI 2.27–3.51), and 6.87 (95% CI 6.33–7.44) for age 65–75, ≥75, and ≥85 years, respectively. Other predictors of stroke or systemic embolism included history of stroke or TIA (HR 2.84, 95% CI 2.19–3.67), hypertension (HR 1.60, 95% CI 1.37–1.86), diabetes (HR 1.28, 95% CI 1.20–1.37), heart failure (HR 1.25, 95% CI 1.11–1.40), peripheral artery disease (pooled HR 1.35, 95% CI 1.04–1.75), vascular disease (pooled HR 1.21, 95% CI 1.06–1.39), and prior myocardial infarction (pooled HR 1.08, 95% CI 1.03–1.14). Female sex was a predictor of thromboembolism in studies outside Asia (HR 1.35, 95% CI 1.15–1.59), but not in those done in Asia (HR 0.95, 95% CI 0.81–1.10). Conclusion This study confirms age and prior stroke as the strongest predictors of stroke or systemic embolism in anticoagulant-naive AF patients. Other predictors include hypertension, diabetes, heart failure, and vascular disease. Female sex seems not to be universally associated with stroke or systemic embolism.

Background Patients with serious mental illness (SMI) have an increased risk of sudden death. Higher rates of signal-averaged electrocardiogram (SAECG) abnormal late potentials (LP), which may be a predictor of sudden death risk, have been shown in patients with schizophrenia. We aimed to assess the prevalence and predictors of electrocardiograph (ECG) and SAECG abnormalities in a mixed SMI population. Methods Consecutive consenting inpatients with SMI had 12-lead ECG and SAECG recorded in addition to demographics, diagnoses and medications. Standard criteria for abnormal SAECG were applied. Multivariate regression analysis was performed to determine predictors of SAECG abnormalities including diagnoses, body mass index, ECG parameters, psychotropic medication use, and medications associated with Long QT or Brugada syndromes. Results Eighty (80) patients, 49% male, mean age 39±17 years were included. SAECG criteria abnormality for 1, 2 or 3 criteria were seen in 19, 3 and 5 cases (34% in total) respectively. Early repolarisation pattern was seen in 19% of patients. SAECG abnormality was associated with male gender (OR 7.3; 95% CI 2.3–23.4), and schizophrenia/schizoaffective disorder diagnosis (OR 7.4; 95% CI 1.9–29.0), but not with medication type or dose. Conclusions In the mixed SMI population studied, there was a high rate of SAECG-detected late potentials (34%) and early repolarisation pattern (19%). Schizophrenia/schizoaffective disorder diagnosis was the strongest multivariate predictor identified. Further studies are needed to define the mechanism and significance of these cardiac abnormalities in SMI patients.

Empirical data regarding dynamic alterations in illicit drug supply markets in response to the COVID-19 pandemic, including the potential for introduction of novel drug substances and/or increased poly-drug combination use at the "street" level, that is, directly proximal to the point of consumption, are currently lacking. Here, a high-throughput strategy employing ambient ionization-mass spectrometry is described for the trace residue identification, characterization, and longitudinal monitoring of illicit drug substances found within6,600 discarded drug paraphernalia (DDP) samples collected during a pilot study of an early warning system for illicit drug use in Melbourne, Australia from August 2020 to February 2021, while significant COVID-19 lockdown conditions were imposed. The utility of this approach is demonstrated for the de novo identification and structural characterization of β-U10, a previously unreported naphthamide analog within the "U-series" of synthetic opioid drugs, including differentiation from its α-U10 isomer without need for sample preparation or chromatographic separation prior to analysis. Notably, β-U10 was observed with 23 other drug substances, most commonly in temporally distinct clusters with heroin, etizolam, and diphenhydramine, and in a total of 182 different poly-drug combinations. Longitudinal monitoring of the number and weekly "average signal intensity" (ASI) values of identified substances, developed here as a semi-quantitative proxy indicator of changes in availability, relative purity and compositions of street level drug samples, revealed that increases in the number of identifications and ASI for β-U10 and etizolam coincided with a 50% decrease in the number of positive detections and an order of magnitude decrease in the ASI for heroin.

Management of atrial fibrillation (AF) requires a comprehensive approach due to the limited success of medical or procedural approaches in isolation. Multiple modifiable risk factors contribute to the development and progression of the underlying substrate, with a heightened risk of progression evident with inadequate risk factor management. With increased mortality, stroke, heart failure and healthcare utilisation linked to AF, international guidelines now strongly support risk factor modification as a critical pillar of AF care due to evidence demonstrating the efficacy of this approach. Effective lifestyle management is key to arrest and reverse the progression of AF, in addition to increasing the likelihood of freedom from arrhythmia following catheter ablation.

Underrepresentation of females in randomized controlled trials (RCTs) limits generalizability and quality of the evidence guiding treatment of females. This study aimed to measure the sex disparities in participants' recruitment in RCTs of atrial fibrillation (AF) and determine associated factors, and to describe the frequency of outcomes reported by sex.MEDLINE was searched to identify RCTs of AF published between January 1, 2011, and November 20, 2021, in 12 top-tier journals. We measured the enrollment of females using the enrollment disparity difference (EDD) which is the difference between the proportion of females in the trial and the proportion of females with AF in the underlying general population (obtained from the Global Burden of Disease). Random-effects meta-analyses of the EDD were performed, and multivariable meta-regression was used to explore factors associated with disparity estimates. We also determined the proportion of trials that included sex-stratified results.Out of 1133 records screened, 142 trials were included, reporting on a total of 133 532 participants. The random-effects summary EDD was -0.125 (95% confidence interval [CI] = -0.143 to -0.108), indicating that females were under-enrolled by 12.5 percentage points. Female enrollment was higher in trials with higher sample size (250 vs.750, adjusted odds ratio [aOR] 1.065, 95% CI: 1.008-1.125), higher mean participants' age (aOR: 1.006, 95% CI: 1.002-1.009), and lower in trials conducted in North America compared to Europe (aOR: 0.945, 95% CI: 0.898-0.995). Only 36 trials (25.4%) reported outcomes by sex, and of these 29 (80.6%) performed statistical testing of the sex-by-treatment interaction.Females remain substantially less represented in RCTs of AF, and sex-stratified reporting of primary outcomes is infrequent. These findings call for urgent action to improve sex equity in enrollment and sex-stratified outcomes' reporting in RCTs of AF.

This study sought to evaluate the role of cardiac afferent reflexes in atrial fibrillation (AF).Efferent autonomic tone is not associated with atrial remodeling and AF persistence. However, the role of cardiac afferents is unknown.Individuals with nonpermanent AF (n = 48) were prospectively studied (23 in the in-AF group and 25 in sinus rhythm [SR]) with 12 matched control subjects. We performed: 1) low-level lower body negative pressure (LBNP), which decreases cardiac volume, offloading predominantly cardiac afferent (volume-sensitive) low-pressure baroreceptors; 2) Valsalva reflex (predominantly arterial high-pressure baroreceptors); and 3) isometric handgrip reflex (both baroreceptors). We measured beat-to-beat mean arterial pressure (MAP) and heart rate (HR). LBNP elicits reflex vasoconstriction, estimated using venous occlusion plethysmography-derived forearm blood flow (∝1/vascular resistance), maintaining MAP. To assess reversibility, we repeated LBNP (same day) after 1-hour low-level tragus stimulation (in n = 5 in the in-AF group and n = 10 in the in-SR group) and6 weeks post-cardioversion (n = 7).The 3 groups were well matched for age (59 ± 12 years, 83% male), body mass index, and risk factors (P = NS). The in-AF group had higher left atrial volume (P 0.001) and resting HR (P = 0.01) but similar MAP (P = 0.7). The normal LBNP vasoconstriction (-49 ± 5%) maintaining MAP (control subjects) was attenuated in the in-SR group (-12 ± 9%; P = 0.005) and dysfunctional in the in-AF group (+11 ± 6%; P 0.001), in which MAP decreased and HR was unchanged. Valsalva was normal throughout. Handgrip MAP response was lowest in the in-AF group (P = 0.01). Interestingly, low-level tragus stimulation and cardioversion improved LBNP vasoconstriction (-48 ± 15%; P = 0.04; and -32 ± 9%; P = 0.02, respectively).Cardiac afferent (volume-sensitive) reflexes are abnormal in AF patients during SR and dysfunctional during AF. This could contribute to AF progression, thus explaining "AF begets AF." (Characterisation of Autonomic function in Atrial Fibrillation [AF-AF Study]; ACTRN12619000186156).

Background Smoking cessation after a first cardiovascular event reduces the risk of recurrent vascular events and mortality. This systematic review and meta-analysis aimed to summarize data on the rates, predictors, and the impact of smoking cessation in patients after a stroke or transient ischemic attack (TIA). Methods MEDLINE, EMBASE and Web of Science were searched to identify all published studies providing relevant data through May 20, 2021. Random-effects meta-analysis method was used to pool proportions. Some findings were summarized narratively. Results Twenty-five studies were included. The pooled smoking cessation rates were 51.0% (8 studies, n = 1738) at 3 months, 44.4% (7 studies, n = 1920) at 6 months, 43.7% (12 studies, n = 1604) at 12 months, and 49.8% (8 studies, n = 2549) at 24 months or more of follow-up. Increased disability and intensive smoking cessation support programs were associated with a higher likelihood of smoking cessation, whereas alcohol consumption and depression had an inverse effect. Two studies showed that patients who quit smoking after a stroke or a TIA had substantially lower risk of recurrent stroke, death, and a composite of stroke, myocardial infarction, and death. Conclusion Smoking cessation in stroke survivors is associated with reduced recurrent vascular events and death. About half of smokers who experience a stroke or a TIA stop smoking afterwards. Those with low post-stroke disability, who consume alcohol, or have depression are less likely to quit. Intensive support programs can increase the likelihood of smoking cessation.

Objective: To summarize data on atrial fibrillation (AF) detection rates and predictors across different rhythm monitoring strategies in patients with cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). Methods: MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through July 6, 2020. Random-effects meta-analysis method was used to pool estimates. Results: We included 47 studies reporting on a pooled population of 8,215 patients with CS or ESUS. Using implantable cardiac monitor (ICM), the pooled rate of AF was 12.2% (95% CI 9.4–15.0) at 3 months, 16.0% (95% CI 13.2–18.8) at 6 months, 18.7% (95% CI 15.7–21.7) at 12 months, 22.8% (95% CI 19.1–26.5) at 24 months, and 28.5% (95% CI 17.6–39.3) at 36 months. AF rates were significantly higher in patients with ESUS vs CS (22.0% vs 14.2%; p

To summarize the evidence underpinning the role of risk factor management in atrial fibrillation (AF) and to describe the key components critical to the successful delivery of this aspect of AF care. Recent studies exploring the role of risk factor management in AF have demonstrated the importance of comprehensively and simultaneously managing all risk factors. Strong evidence exists to support the aggressive management of overweight and obesity, hypertension, diabetes, obstructive sleep apnea, alcohol excess, and physical inactivity in improving outcomes in this population. Other factors, such as dyslipidemia, are managed according to individual cardiovascular risk. The use of protocol-driven care, assisted by a checklist, is critical to ensure that all risk factors are comprehensively addressed in a standardized fashion. Engaging the patient through the health behavior change process, by assessing importance and confidence in achieving the desired change and goal setting to achieve targets, increases the likelihood of success. Regular reviews and feedback are essential to ensure accountability and ongoing engagement. Risk factor management is an essential pillar of AF care that should be incorporated alongside appropriate use of oral anticoagulation, rate control, and rhythm management. Successful implementation of this aspect of comprehensive AF management requires a protocol-driven approach with regular follow-up to maximize patient engagement.

To summarize data on the prevalence/incidence, risk factors and prognosis of atrial fibrillation (AF) in patients with acute pulmonary embolism (aPE).MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through December 12, 2021. Random-effects meta-analysis method was used to pool estimates.We included 27 studies reporting data from a pooled population of 819,380 patients. The prevalence rates were 11.3% for pre-existing AF, 4.7% for newly diagnosed AF, and 13.2% for prevalent (total) AF. Predictors of newly diagnosed AF (from one study) included congestive heart failure (adjusted odds ratio [aOR] 3.33, 95% CI: 1.81-6.12), ischemic heart disease (aOR 3.25, 95% CI: 1.65-6.39), massive PE (aOR 2.67, 95% CI: 1.19-5.99). Overall, AF was associated with increased risk of short-term (aOR 1.54, 95% CI: 1.44-1.64) and long-term mortality (aOR 1.58, 95% CI: 1.26-1.97). In subgroup analyses, all types of AF were associated with increased risk of short-term mortality: pre-existing AF (aOR 1.90, 95% CI: 1.59-2.27), newly diagnosed AF (aOR 1.51, 95% CI: 1.18-1.93), and prevalent AF (aOR 1.50, 95% CI: 1.42-1.60). Pre-existing AF (aOR 2.08, 95% CI: 1.27-3.42) and prevalent AF (aOR 1.29, 95% CI: 1.02-1.63) were also associated with higher long-term mortality.AF is present in about one in eight patients with aPE, and is associated with increased short- and long-term mortality. AF might improve risk stratification in patients with aPE.

Objective This review aimed to summarize the evidence on the risk of thromboembolism associated with carotid and aortic atherosclerosis in patients with AF, and the potential impact of their inclusion in current stroke risk stratification scores. Methods MEDLINE, Web of Science and EMBASE were systematically searched to identify all published studies providing relevant data through 28 February 2021. Results We identified 10 eligible studies. There was high heterogeneity across studies, precluding a meta-analysis. Carotid stenosis was not associated with incident ischemic stroke in three prospective studies, including the SPAF II trial and the ROCKET-AF trial. An association between carotid stenosis and thromboembolism was found in two studies, with a potential reporting bias due to their retrospective design. The evidence suggesting that carotid plaque predicts stroke or transient ischemic attack in AF patients were more consistent in the four studies evaluating this association. The inclusion of carotid plaque and carotid intima-media thickness (cIMT) into stroke risk stratification tools for AF patients improved their performance. Data on the association of aortic plaque with thromboembolism is scarce in patients with AF. The two studies reporting on this association suggest that aortic plaque alone does not predict incident ischemic stroke. Conclusion Available data suggest an association of carotid atherosclerosis with the risk of stroke and transient ischemic attack in patients with AF. Future studies should evaluate whether incorporating cIMT and characteristics of carotid and aortic plaques into scoring systems would improve stroke prediction and prevention in patients with AF.

Empirical approaches to targeting the ventricular tachycardia (VT) substrate include mapping of late potentials, local abnormal electrogram, pace-mapping and homogenisation of the abnormal signals. These approaches do not try to differentiate between the passive or active role of local signals as the critical components of the VT circuit. By not considering the functional components, these approaches often view the substrate as a fixed anatomical barrier. Strategies to improve the success of VT ablation need to include the identification of critical functional substrate. Decrement-evoked potential (DeEP) mapping has been developed to elucidate this using an extra-stimulus added to a pacing drive train. With knowledge translation in mind, the authors detail the evolution of the DeEP concept by way of a study of simultaneous panoramic endocardial mapping in VT ablation; an in silico modelling study to demonstrate the factors influencing DeEPs; a multicentre VT ablation validation study; a practical approach to DeEP mapping; the potential utility of DeEPs to identify arrhythmogenic atrial substrate; and, finally, other functional mapping strategies.

Atrial fibrillation (AF) and carotid stenosis (CS) can coexist and this association has been reported to result in a higher risk of stroke than attributed to either condition alone. Here we aimed to summarize the data on the association of CS and AF. MEDLINE and Embase were searched to identify all published studies providing relevant data through February 27, 2020. Random-effects meta-analysis method was used to pool estimates of prevalence. Heterogeneity was assessed by mean I-squared statistic. Forty-eight studies were included, 20 reporting on the prevalence of carotid disease in a pooled population of 49,070 AF patients, and 28 on the prevalence of AF in a total of 2,288,265 patients with carotid disease. The pooled prevalence of CS in AF patients was 12.4% (95% confidence interval [CI] 8.7 to 16.0, I2 93%; n = 3,919), ranging from 4.4% to 24.3%. The pooled prevalence of carotid plaque was 48.4% (95% CI 35.2 to 61.7, I2 = 99%; n = 4292). The prevalence of AF in patients with CS was 9.3% (95% CI 8.7 to 10.0, I2 99%; n = 2,286,518), ranging from 3.6% to 10.0%. This prevalence was much higher (p 0.05). In conclusion, AF and CS frequently coexist, with about one in ten patients with AF having CS, and vice versa. In addition, nonstenotic carotid disease is present in about half of AF patients. These findings have important implications for AF screening in patients with CS, stroke prevention, and the opportunities to intervene on common risk factors.

Left ventricular access for aortic valve intervention provides the opportunity to deliver rapid pacing over the guidewire for device positioning and deployment. Temporary pacing delivered via the left ventricle can obviate the need for venous access and has been shown to be a safe alternative to temporary right ventricular pacing. The technique requires some basic knowledge and experience in temporary cardiac pacing. We outline safe practical steps and common pitfalls in using this technique.

On 14 March 2014 CNBC stock market TV commentator Jim Cramer was crazily excited about a rapid rise in the stock price of GW Pharmaceuticals after positive phase III test results for cannabinoid drug Epidiolex (cannabidiol). He observed that the stock price rise was not due to the potential for its use in child epilepsy (what the phase III trials were for), but due to the potential introduction of GW Pharmaceuticals into the pain relief market as a replacement for oxycodone. The market response was clear, pain management was a growth industry. In 2015 the global pain management market for pharmaceuticals was estimated at $36.6bn. Growth is noted particularly in the ageing population (cancer pain), increased incidence in obesity (driving musculoskeletal problems) and in changing attitudes to pain management after the oxycodone epidemic. This chapter maps out the rising fortunes of the cannabis pain relief market. Through looking at the rise of cannabis industries and the various ways governments across the globe are trying to extract capital through licensing and taxation, the neuromatrix extends from the individual into a discussion of how the state can extract economic value from pain. Through modulations in the perceived value of pain, private companies, governments and financial systems are readying themselves for a new commodification of pain.

Early in this chapter I introduce Melzack’s concept of the neuromatrix and then extend it beyond the human brain into a wider metaphor for a cultural neuromatrix. I will extract what I believe are the functional principles underpinning this matrix metaphor (such as organisation, modulation, signature ghosts and interoceptive modelling) and apply these in more abstract terms. The chapter then will progress to the more social and cultural dimensions of the pain neuromatrix. Two articulations of the social dimensions to pain will be described. A key element of the cultural neuromatrix are cultural neurosignatures, the refrains that capture pain and fashion it into specific forms and relationships. In the final section I will introduce the idea that pain is a commodity and underpinning its value as a commodity is its capacity to shapeshift. It is this shapeshifting capacity that reveals the derivative logic to commodity pain.

The use of over-the-counter (OTC) analgesics reflects the degree to which the population is allowed to engage in the self-treatment of pain. Regulation of the advertising practices for OTC analgesics is usually the remit of a government agency tasked to assess the efficacy and safety of medicines, and to respond to complaints about false or misleading advertising. Following the opioid epidemic in the United States, greater attention has been placed on reducing access to OTC opioid analgesics such as codeine. In 2018, the Australian Therapeutic Goods Administration (TGA) “up-scheduled” codeine, such that it is now only available by prescription. Reducing access to codeine was argued to be necessary because of the addictive qualities of codeine and the risk it poses for both codeine mortality and the development of demand for stronger opioid analgesics such as oxycodone. This regulatory move was seen as a necessary preventive intervention to avoid a North American-style opioid epidemic in Australia. The pain of the North American opioid epidemic was somehow contagious. In this chapter the consequences of contagious pain are explored in terms of what happens when the self-management of pain is curtailed, for fear that a segment of the population will abuse pain relievers. The impacts are mapped, not in terms of alternative analgesic consumption (both legal or illegal), but in terms of the vulnerability of this segment of pain sufferers to cultural pain neurosignatures created by big pharma through market mechanisms. The chapter will begin with an analysis of the rationale for codeine up-scheduling, and then develop through an analysis of a cultural pain neurosignature—a marketing campaign for paracetamol—and conclude with an explication of the deployment of biopower through leaving this segment of pain sufferers to the mercy of some of the world’s most powerful marketing forces. This chapter illustrates the deeper problems caused by codifying pain in narrow objectivist terms. Regulation of OTC opioid analgesics is not an evidence-based rational process. This chapter reveals how affective contagion produces an evidential ellipsis, leaving the door open for the cannabis markets to emerge as the big winners from pain.

Pain is inherently productive. There is no getting outside of this. It will continue to be at the centre of life as it is at the centre of Being-in-the-world. At the heart of a better regulatory approach to pain are a set of parameters derived from the acknowledgement of the cultural basis for pain through the cultural pain neuromatrix: diffuse, autonomous, identifiable through neurosignatures and the recruitment of machines across different milieu. Whilst the brain neuromatrix operates through a less than cognitive register, the cultural pain neuromatrix requires conscious engagement. Regulation of pain needs to extend beyond the regulation of pharmaceuticals through therapeutic goods bureaucracies. Implicit in this is a codification of pain that goes beyond linear causal pathways and an acknowledgement of the a-signifying processes that automate cultural responses to pain.

Very powerful in constructing the image of drug user suffering is a genre of websites that “demonstrate” the impact of drug addiction through the physical transformation of drug user faces. Websites such as “Faces of Meth” and “Faces of Addiction”, emerging either from police or the drug rehabilitation industry, trace the changes in drug user faces over time, usually showing the pain of extreme degeneration. Whilst there is an obvious critique of these strategies in terms of mobilising fear and the construction of horror, there is a deeper question as to how do we read pain in people faces and what sort of pain do we recognise when we see the faces of drug users in these types of images. The technique of reading the pain in faces has an ancient history, however 20th century medicine, re-recognised the face of pain through the 1934 work of German physician and photographer Hans Killian. The title of his work “Facies Dolorosa” assumed a clinical meaning. In recent times, reading pain from faces has been applied to a wide range of applications. In the case of drug users, reading faces is a primary mechanism to culturally inscribe pain. There are now algorithms for reading facial musculature, to provide an “objective” account of this subjective state. In this chapter I explore the rendering of the pain of drug user faces on “face-of-drugs” websites and how the reading of pain and violence in drug user faces has material impacts on how we read the faces of methamphetamine users and construct methamphetamine epidemics. I will then explore how this transformation of pain into a corporeal state creates affects. This rendering has significant implications for the cultural pain neuromatrix and how we communicate the pain of drug use. There are material consequences from etching the pain of drugs into faces.

In this chapter I tell a story about the opioid epidemic in North America. The cultural neuromatrix framework implicates a wider set of actors in the propagation of the epidemic. Rather than just blame bad pharma and its compliant regulators, this chapter offers an alternative explanation for the epidemic. In this chapter it is the shapeshifting quality of pain as a commodity that enables a networked affective economy to thrive. Affective capitalism is at the heart of the oxycodone epidemic in North America. Although oxycodone was the reliever that was consumed, it actually only covaried with pain, the real commodity in this economy. When regulators began to reduce access to oxycodone, the third wave of the epidemic began with a range of other synthetic opiates. Once North America unleashed the pain tiger, it has been hard to put back in the box. Cannabis has been primed as the next substance in line to mitigate the pain epidemic that has swept North America. The problem is that the epidemic has been misdiagnosed. It is affective capitalism that is at the heart of pain.

Objectives: The prevalence of regular and dependent methamphetamine use in Australia in 2013/14 was recently estimated indirectly using multipliers at 268,000 regular (defined as >monthly use in the past 6 months) and 160,000 dependent (defined as >3 on the Severity of Dependence Scale) methamphetamine consumers, respectively. We replicated this approach using more contemporary multipliers and alternate data sources to explore identified limitations with this approach. Design: Two multipliers were derived from surveys of methamphetamine consumption in Sydney (NSW) in 2003/04 (the original multiplier) and Melbourne (VIC) in 2010 (a more contemporary multiplier), and applied to the time series of treatment utilisation figures for NSW and VIC, along with ABS-estimated resident population figures. Results: Using the more contemporary VIC multiplier, we estimated numbers of regular (67,250, 95% CI = 50,312-91,635) and dependent (43,232, 95% CI = 34,477-57,947) methamphetamine users for Australia in 2013/14. This is approximately one-third of the figures reported previously. Our national estimates using the 2003/04 NSW multiplier applied to NSW treatment data (175,452, 95% CI = 124,514-256,575 for regular, and 103,761, 95% CI = 73,576-154,699 dependent, methamphetamine users respectively) are approximately two-thirds of the figures reported previously. Conclusions: We urge caution in using treatment multipliers to estimate the prevalence of illicit drug use, particularly during periods of dramatic changes in treatment system capacity, user behaviour, drug purity and policing practices.

SUMMARY A randomized-controlled trial (RCT) was conducted from September 2009 to June 2011. National Diabetes Services Scheme registrants diagnosed with type 2 diabetes and aged 30 –70 years were invited to participate in a 3-week intervention programme with follow-up at 4 weeks and 6 months. Data were collected using self-report questionnaires in the participant’s homes. The intervention group received diabetes factsheets and a DVD comprising patient stories (narratives) of type 2 diabetes management. The control group (CG) received factsheets only. The RCT evaluated the impact of patient narratives on the study outcomes, self-efficacy and self-care, using the Aust/ English Diabetes Management Self-efficacy Scale and the Summary Diabetes Self-care Activities measure. Participants were randomly assigned to the intervention or CG using block randomization. The study was not blinded. Six hundred and seventy people enrolled into the study with 335 allocated to each group. At 4 weeks, data were available for 598 participants. t-tests were used to analyse the results. The mean difference between the groups for self-efficacy was 7.2 units (P , 0.001, 95% Confidence Interval (CI) 3.8, 10.7) favouring the intervention group. Change in self-care behaviours during the previous 7 days was also significantly greater for the intervention group: general diet (0.31 days, 95% CI 0.13, 0.48), specific diet (0.26 days, 95% CI 0.05, 0.46), exercise (0.51 days, 95% CI 0.23, 0.80), blood glucose (0.52 days, 95% CI 0.19, 0.85) and foot care (0.38 days, 95% CI 0.06, 0.71). Narrative communication shows promise as a valuable component of type 2 diabetes self-management programmes. Registration: ACTRN 12609000210279.

In 2006, 2010, and 2011 attempts were made by health policy advocates to ignite policy debate about the introduction of supervised injecting facilities (SIFs) in Melbourne, Australia. Although there have been a number of attempts to introduce SIFs in Australia, only one facility has been introduced in Sydney, and it has only recently achieved full operating status beyond an extended nine-year trial period. This article retraces the policy narratives in documentary materials (parliamentary debates, policy documents, public advocacy and empirical research) to reflect on the causes for policy impermeability in this contested arena. Interest in supervised injecting rooms, whilst always an exemplar of harm reduction, actually emerged in New South Wales in the mid-1990s from government concern over endemic police corruption. Subsequent policy narratives in Victorian SIF advocacy tended to focus heavily on the health and welfare of drug users, with a notable absence of concern about SIFs as a response to police ...

Introduction and Aims. This study describes levels and predictors of community attitudes towards alcohol, support for structural alterations to the drinking context, and intention to increase participation in community sports clubs. Design and Methods. Cross-sectional data were obtained from the VicHealth Community Attitudes Survey on Healthy Sporting Environments, administered to a random sample of Victorian adults. Descriptive and multivariate logistic regression analysis was undertaken. Results. Very high support for removing alcohol sponsorship of community sport and for a levy on alcohol advertising was found. The groups most supportive of breaking the nexus between alcohol and community sport were female, older-aged and non-English-speaking citizens and those not involved in sport clubs. If alcohol sales at community sports clubs were reduced, participation may increase among population groups currently identified as least engaged with community sport. Discussion and Conclusions. An optimal climate exists for policy reforms to make community sporting environments healthier by reducing the ties with alcohol. If implemented, these reforms may lead to an increase and diversification of participants in community sport.[Tobin CL, Fitzgerald JL, Livingstone C, Thomson L, Harper TA. Support for breaking the nexus between alcohol and community sports settings: Findings from the VicHealth Community Attitudes Survey in Australia. Drug Alcohol Rev 2011]. Language: en

INTRODUCTION AND AIMS: To identify general and specific features of health information warning labels on alcohol beverage containers that could potentially inform the development and implementation of a new labelling regime in Australia. DESIGN AND METHODS: Mixed methods, including a cross-sectional population survey and a qualitative study of knowledge, attitudes and behaviours regarding alcohol beverage labelling. The population survey used computer-assisted telephone interviews of 1500 persons in Victoria, Australia to gauge the level of support for health information and warning labels. The qualitative study used six focus groups to test the suitability of 12 prototype labels that were placed in situ on a variety of alcohol beverage containers. RESULTS: The telephone survey found 80% to 90% support for a range of information that could potentially be mandated by government authorities for inclusion on labels (nutritional information, alcohol content, health warning, images). Focus group testing of the prototype label designs found that labels should be integrated with other alcohol-related health messages, such as government social advertising campaigns, and specific labels should be matched appropriately to specific consumer groups and beverage types. DISCUSSION AND CONCLUSION: There are high levels of public support for health information and warning labels on alcohol beverages. This study contributes much needed empirical guidance for developing alcohol beverage labelling strategies in an Australian context.

The pharmacologically addicted body has emerged in recent times as a dominant image shaping drug discourse. Implicit in this image is a drug desire that overpowers and over-determines the individual. A key feature of this particular drug user body is the body as degenerative with drugs as the cause of social suffering through reducing the social agency of the drug user. Likewise the image of the addict with a hardwired primitive desire for drugs use has also gained some ascendancy in scientific literature. Film, popular culture, ethnographic and scientific research can all draw on these images of desire to structure their narratives of drug use. In this paper I explore a different reading of two portrayals of drug desire. Using a range of analytic tools such as narrative analysis, semiotic and post-structuralist analysis I suggest an alternative way to engage with images of desire. Without arguing for a particular way of thinking about the desire to use drugs, this piece illuminates some key questions about images of drug desire. Through being performative, drug icons are productive; they make possible ways of conceptualising the drug user and the drug-using body. The performativity of the image can be thought through traditional semiotics, narrative performativity or, in a more abstract manner with contemporary theories of affect. The point of this essay is to open up another way of thinking about how images might create that of which they speak and in the process suggest a different configuration of desire to the primitive desire of the pharmacologically addicted body.

OBJECTIVES: To examine self-reported patterns of alcohol consumption and experience of alcohol-related harms among professional Australian Football League (AFL) players. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional survey of player alcohol consumption and self-reported alcohol-related harms among members of all 16 professional AFL clubs. Data relating to the 2006 football year were collected between 25 July and 30 August 2006 at regular football training sessions using a self-administered structured questionnaire. MAIN OUTCOME MEASURES: Risky/high-risk drinking for long- and short-term harm at different times of the year; Alcohol Use Disorders Identification Test (AUDIT) score. RESULTS: 582 AFL players completed the questionnaire (an 83% response rate). Alcohol consumption varied at different times of the year. During the playing season (approximately 22 weeks), the level of risky/high-risk consumption for long-term harm in AFL players (11/564 [2%]) was typically lower than in age-matched Australian men in the general population (15%). However, risky/high-risk consumption for long-term harm was higher in AFL players during the end-of-season period (approximately 2 weeks) (303/561 [54%]) and vacation period (6-8 weeks) (231/559 [41%]) than in age-matched Australian men. Risky/high-risk drinking for short-term harm on a monthly basis was frequent at all times of the year (eg, 395/560 [71%] in the pre-season period). The mean AUDIT score was 8.8 (95% CI, 8.4 to 9.1; range, 0 to 36). Reports of harmful effects of drinking and negative consequences, such as getting involved in a fight (physical or verbal) while drinking (146/556 [26%]), were common. Risky/high-risk consumption for short-term harm on a monthly basis was associated with a variety of player characteristics, such as usually drinking in public locations (odds ratio, 1.55 [95% CI, 1.02 to 2.35]). AUDIT score was associated with variables such as marital status, with married players scoring more than two points lower (95% CI, - 3.58 to - 0.58) than single players. Formal club rules on alcohol consumption had little effect on outcome measures. CONCLUSIONS: Drinking among AFL players is intricately related to time of year. This seasonal drinking pattern requires the development of specific club and league strategies to minimise drinking-related harms to players. Language: en

How do street-based injecting drug using women negotiate the myriad day to day risks of injecting in public urban space whilst, at the same time, negotiate the gendered discourses surrounding space and drug use, which work to both limit their bodily movements and position them as ‘dirty’, ‘diseased’ and ‘dangerous’? How do they avoid overdose, violence, arrest and disease, whilst at the same time avoid becoming—and being treated as—a ‘leper’ or ‘junkie’? In this article we draw on the interview narratives of 14 women who regularly inject in various public city spaces in Melbourne, Australia, in order to explore their negotiations of this complex gender/space/drug-use nexus of risk. Using Deleuze's concept of the ‘fold’, along with Butler's concept of ‘performative’ identity, we explore the ways in which women injecting drug users, through their embodied performances and their narratives of space and risk, enfold and unfold the spaces and discourses they encounter. We suggest that the ways in which these f...

Seeing comes before words. The child looks and recognizes before it can speak. But there is also another sense in which seeing comes before words. It is seeing which establishes our place in the su...

The Australian National Council on Drugs (ANCD) was introduced into the Australian drug policy community in 1997 by the Howard conservative government as part of its “Tough on Drugs” policy initiative. Support in 1997 by the states and territories through the Ministerial Council on Drug Strategy (MCDS) for a trial of prescribed heroin prompted the prime minister to attempt to directly control drug policy by changing national drug-policy-making processes. It has been suggested that the ANCD was introduced to short-circuit the power of the states and territories to structure national drug strategy, signaling a shift from consensus decision making through a policy community approach to centralized executive decision making through the prime minister's office. Interviews with key policy makers during 1999–2000 and findings from recent evaluations point to a climate of distrust, over-bureaucratization, slow decision making, and overt paranoia about the presence of new players in the drug policy arena, resulting not from inadequacies in governance but as a resistant response from policy makers to the introduction of the ANCD. This shift in the model of decision making may lead to an obsolete national drug strategy (NDS) and undermine a unified approach to national drug policy.