Effects of palliative intrathecal analgesia on patients with refractory cancer bone pain.

This study examined the effects of intrathecal analgesia (ITA) using an extracorporeal pump with a subcutaneous port system in cancer patients with bone metastasis. Among the patients who died of cancer with bone metastasis at the palliative care unit of our institution, 11 who received ITA were selected. Changes in pain, opioid doses, the palliative prognostic index (PPI), and Eastern Cooperative Oncology Group Performance Scale　after ITA were assessed. Pain, opioid doses, and PPI decreased after ITA (P = 0.002, 0.002, and 0.017). ITA for cancer patients with increased PPI due to refractory cancer bone pain decreased pain, opioid doses, and PPI.(100 words).

[Analysis of Patients Discharged from a Palliative Care Unit].

For terminal-phase cancer patients, being discharged from a palliative care unit(PCU)is often challenging. To explore this reason, we compared patients who went home alive from the PCU with patients who died in the same unit. Among the survival cases, the average duration from their diagnosis to admission into the PCU was longer. Their slow progressions might allow them to leave the PCU. Patients with head and neck cancer were more often among those who died in the PCU, and the ratio of patient with endometrial cancer was higher in the survival cases. These ratios were relevant to the duration before their admission and variety of their symptoms.

Effect of face shield design on the prevention of sneeze droplet inhalation.

A flow simulation was performed for face shields to investigate whether varying a shield's edge shape could prevent droplets from entering the shield. Face shields with two types of edge shapes were used. The "Type I" shield had small plates mounted on the top and bottom edges of the shield to physically inhibit the sneeze inflow. The "Type II" shield had small brims sticking forward from the shield surface and small plates sticking upward and downward at the top and bottom edges to inhibit the entrainment flow produced by the vortex ring using sneeze flow. We confirmed that the flow characteristics around a face shield can be controlled using the shield's edge shape. In Type I, the entraining flow inside the shield was inhibited by the mounted small plate at the bottom edge, ensuring the inhibiting effect, but not at the top edge. In Type II, the entrained flow inside the shield was inhibited by the mounted brim and small plate at the top edge, ensuring the inhibiting effect, but not at the bottom edge. The effects of the Type II design parameters on the flow characteristics around the face shield were examined. The results indicate that at the top edge, increasing the length of the brim and not mounting the small plate at an incline from the shield surface improves the inhibition effect. At the bottom edge, shortening the length of the brim and mounting the small plate at an incline from the shield surface improves the inhibition effect.

Effect of sneezing on the flow around a face shield.

A flow analysis around a face shield was performed to examine the risk of virus infection when a medical worker wearing a face shield is exposed to a patient's sneeze from the front. We ensured a space between the shield surface and the face of the human model to imitate the most popularly used face shields. In the present simulation, a large eddy simulation was conducted to simulate the vortex structure generated by the sneezing flow near the face shield. It was confirmed that the airflow in the space between the face shield and the face was observed to vary with human respiration. The high-velocity flow created by sneezing or coughing generates vortex ring structures, which gradually become unstable and deform in three dimensions. Vortex rings reach the top and bottom edges of the shield and form a high-velocity entrainment flow. It is suggested that vortex rings capture small-sized particles, i.e., sneezing droplets and aerosols, and transport them to the top and bottom edges of the face shield because vortex rings have the ability to transport microparticles. It was also confirmed that some particles (in this simulation, 4.4% of the released droplets) entered the inside of the face shield and reached the vicinity of the nose. This indicates that a medical worker wearing a face shield may inhale the transported droplets or aerosol if the time when the vortex rings reach the face shield is synchronized with the inhalation period of breathing.

Bacterial contamination upon the opening of injection needles.

INTRODUCTION: Two opening methods are used for injection needle products: the "peel-apart method" where the adhesive surface of the packaging mount is peeled off, and the "push-off top method," where the needle hub is pressed against the mount to break it. However, the risks of bacterial contamination as a result of opening method remain unknown. The aim of our study was to evaluate the bacterial contamination of needle hubs upon the opening of injection needles by the peel-apart or push-off top method under various conditions. METHODS: Bacterial contamination upon the opening of injection needles was examined in two materials, paper and plastic. Various concentrations of Staphylococcus aureus were applied to the mount and were maintained under wet or dry conditions. Injection needles were opened using the peel-apart or push-off top method. Needle hub contamination was examined using agar medium colony counting. Clinically assumed conditions (the hands and saliva of anesthesiologists) were also evaluated. Data were statistically examined using the Cochran-Mantel-Haenszel, Jonckheere, and Fisher's exact tests. RESULTS: The lateral surfaces of needle hubs were contaminated using the push-off top method, but not by the peel-apart method, in a manner that was dependent on S. aureus concentrations. No significant differences were observed between mount materials. Needle hub contamination was significantly more severe for the wet than for the dry opening portion. The clinically assumed condition study revealed that the lateral and bottom surfaces of the needle hub were contaminated significantly more in the saliva contamination group than in the dry and wet hand groups. CONCLUSIONS: The bacterial contamination of needle hubs may occur upon the opening of injection needles when the push-off top method is used and may be affected by hands contaminated with saliva under clinical conditions.

Increased biofilm formation ability and accelerated transport of Staphylococcus aureus along a catheter during reciprocal movements.

Staphylococcus spp. is a major cause of device-related infections. However, the mechanisms of deep-tissue infection by staphylococci from the skin surface remain unclear. We performed in vitro experiments to determine how staphylococci are transferred from the surface to the deeper layers of agar along the catheter for different strains of Staphylococcus aureus with respect to bacterial concentrations, catheter movements, and biofilm formation. We found that when 5-mm reciprocal movements of the catheter were repeated every 8h, all catheter samples of S. aureus penetrated the typical distance of 50mm from the skin to the epidural space. The number of reciprocal catheter movements and the depth of bacterial growth were correlated. A greater regression coefficient for different strains implied faster bacterial growth. Enhanced biofilm formation by different strains implied larger regression coefficients. Increased biofilm formation ability may accelerate S. aureus transport along a catheter due to physical movements by patients.

[Skin lesions on the back along the epidural Catheter].

We report a patient with anemia and hypoalbuminemia who developed decubitus ulcer along the epidural catheter. A 35-year-old woman underwent cesarean section under combined spinal-epidural anesthesia. Erosive and erythematous skin lesions along the epidural catheter were noted 48 hours after insertion of the epidural catheter. The skin lesions were thought to be decubitus ulcer along the epidural catheter due to mechanical pressure caused by fixation of the catheter with an adhesive tape after prolonged supine position.

[Spontaneous spinal subdural and epidural haematoma in a pregnant patient].

We report a pregnant woman who developed non-traumatic spinal subdural and epidural hematoma. A 31-year-old woman at 28 weeks of gestation developed progressive ascending paralysis. MRI suggested the presence of spinal subdural hematoma at T4-6 and spinal epidural hematoma at T4-9. An emergency cesarean section followed by spinal decompression was performed 60 hours after the onset. The patient's neulogical function recovered completely after the surgey.

[Aseptic precautions in epidural catheterization for surgery].

We describe aseptic precautions in epidural catheterization for surgery. Every patient has to be checked for immunodeficiency, atopic dermatitis, preoperative use of antibiotics, and local infection of the epidural puncture site. Physicians who perform epidural catheterization should wear a mask and a cap and take off a wrist watch and rings on the fingers before an epidural kit is opened. Fingers and hands should be disinfected before wearing surgical gloves. The skin for epidural puncture site should be disinfected with 0.5% chlorhexidine in 80% ethanol. A micropore filter should be used when epidural catheterization is expected to remain over 24 hours.

[Monitoring of muscle relaxation at the corrugator supercilli muscle in a patient with atrophied upper limbs].

We report a patient whose muscle relaxation was monitored at the corrugator supercilli muscle. In a 51-year-old woman with markedly atrophied upper limbs, anesthesia was induced with propofol and fentanyl. Muscle relaxation was monitored at the adductor pollicis and corrugator supercilli muscles with accelomyography. Train-of-four ratio (TOFR) could be evaluated at the corrugator supercilli muscle; however, it could not be evaluated at the adductor pollicis muscle. The trachea was intubated when the TOFR was 0.09 at the corrugator supercilli muscle after intravenous vecuronium. As the TOFR was 1.44 when the surgery completed, the trachea was extubated without giving neostigmine to antagonize the effect of vecuronium. There was no recurarization after extubation. We conclude that evaluation of TOFR at the corrugator supercilli muscle is useful in some patients who have atrophied adductor pollicis muscle.

Method of detecting beta-lactam antibiotic induced vancomycin resistant MRSA (BIVR).

Despite the fact that the combination of vancomycin and a beta-lactam antibiotic are known to act synergistically on vancomycin-susceptible Staphylococcus aureus (VSSA), some MRSA have emerged showing antagonism to the combination of vancomycin and a beta-lactam antibiotic. These MRSA are called beta-lactam antibiotic-induced vancomycin resistant MRSA (BIVR). A method based on this antagonistic phenomenon has been devised to detect BIVR strains. The method inhibits the VSSA strain but allows the BIVR strain to grow. Forty-six commercially available beta-lactam antibiotics induced the vancomycin-resistance. Using this detection method, 717 MRSA clinical isolates obtained from eight institutes throughout Japan were thus screened and 6.3% of these were detected as BIVR when judged at 48 h.

Emergence of vancomycin resistance during therapy against methicillin-resistant Staphylococcus aureus in a burn patient--importance of low-level resistance to vancomycin.

OBJECTIVES: Staphylococcus aureus with low-level resistance to vancomycin (VLSA) which could develop into vancomycin-resistant S. aureus (VRSA) is most important. However, VLSA is difficult to detect by standard laboratory methods. We describe here improved methods to detect VLSA. METHODS: Three methicillin-resistant S. aureus (MRSA) strains, designated Fu6, Fu10, and Fu18, were sequentially isolated from the burn wound site of a patient, during vancomycin therapy. The properties of these strains were compared with those of reference strains Mu3 and Mu50 (previous resistant isolates from other patients). RESULTS: The isolated strains, Fu10 and Fu18, had identical phenotypes and genotypes. The vancomycin resistance of Fu10 was equivalent to that of strain Mu3, whereas Fu18 had much higher vancomycin resistance than Fu10 and Mu3, although reaching the level of Mu50. Fu18 showed similar growth to Mu50 on gradient gels and on Mu3 medium. CONCLUSIONS: Our data indicate that the VLSA developed vancomycin resistance during exposure to vancomycin in vivo. The population analysis of tested VLSA and vancomycin intermediately resistant S. aureus (VISA) indicates that a penem at relatively low concentrations induced a significant increase in the number of vancomycin-resistant subpopulations. Furthermore, we confirmed that gradient gel analysis and Mu3 medium are simple and useful methods for the detection of VLSA judged as VSSA by its conventional MIC alone.