Hyaluronidase for localised infusion site reaction during continuous subcutaneous infusion.

Local skin site reactions may occur at continuous subcutaneous infusion (CSCI) sites. Factors that contribute these reactions include the concentration of medications, the pH of the solution, type and duration of cannula insertion and site selection. The case of a patient with advanced metastatic cholangiocarcinoma is described. Medications were delivered subcutaneously via a syringe driver and multiple infusion site reactions occurred. Hyaluronidase temporarily depolymerises hyaluronic acid in connective tissue and been has been shown to increase the dispersion and absorption of coadministered molecules. A single dose of 150 IU hyaluronidase was injected into the subcutaneous site prior to commencement of the syringe driver. Subsequent skin site erythema and tenderness was observed. Hyaluronidase may be indicated for use as an adjunct to increase the absorption and dispersion of injected drugs as well as for subcutaneous fluid rehydration. There is, however. limited evidence to indicate its use in skin site reactions and it may contribute to poor tolerance of a CSCI. To the author's knowledge, this is the first case report of the use of hyaluronidase in the management of infusion site skin reactions.

Pediatric oncology and stem cell transplant patients with healthcare-associated Clostridium difficile infection were already colonized on admission.

Clostridium difficile is the leading cause of healthcare-associated infections worldwide. The diagnosis of C. difficile infection (CDI) in pediatric oncology patients is complex as diarrhea is common, and there is a high rate of colonization in infants and young children. This study was conducted to assess the accuracy of the surveillance definitions of healthcare-associated CDI (HA-CDI) and to determine the prevalence of toxigenic C. difficile colonization among pediatric oncology and stem cell transplant patients. METHODS: A prospective cohort study was conducted over a three-year period in an inpatient pediatric oncology and stem cell transplant setting. Baseline stool samples were collected within three days of admission and were genotypically compared with clinically indicated samples submitted after three days of admission. RESULTS: A total of 175 patients were recruited with a total of 536 admissions. The adjusted prevalence of baseline toxigenic C. difficile colonization among admissions was 32.8%. Seventy-eight percent of positive admissions did not have history of CDI. Colonization with a toxigenic strain on admission was predictive of CDI (OR = 28.6; 95% CI, 6.58-124.39; P < 0.001). Nearly all clinical isolates (8/9) shared identical pulsed-field gel electrophoresis patterns with baseline isolates or were closely related (1/9). Only one of the 11 cases that were considered HA-CDI was potentially nosocomially acquired. CONCLUSION: The prevalence of colonization with toxigenic C. difficile in our cohort is high. Unfortunately, the current CDI surveillance definitions overestimate the incidence of HA-CDI in pediatric oncology and stem cell transplantation settings.

Caregivers experiences of managing medications for palliative care patients at the end of life: a qualitative study.

Informal caregivers are important in enabling palliative care patients to die at home, including their role in managing medications. Often these patients are taking multiple medications, imposing an unnecessary burden on those who are already struggling with oral intake. A literature review revealed that, while there are a number of qualitative studies published examining the experience of caregivers looking after patients at the end of life, there is a dearth of published studies specifically examining the impact of managing medications on caregivers. This study explores the experience of caregivers managing medications for patients dying at home, focusing on the impact of polypharmacy, the use of syringe drivers and the use of "as needed" medications for symptom control. Three focus groups were performed, involving bereaved caregivers of patients that had died at home, and were analysed using content thematic analysis. Themes that emerged include: the significant burden of polypharmacy; the positive impact of subcutaneous infusions; the value of being able to give medications as needed for symptom control; the importance of clear guidance to assist with medication management. Strategies are suggested that might ease the burden of medications at the end of life.

Hair tourniquet management.

Unwind or incise has been the standard of management for removing hair tourniquets. The hair ends are usually difficult to hold and unwind as they break at the ends easily, and using scalpels or needles to get under the hair tourniquet is difficult when the involved appendage is swollen and leads to more trauma to the injured area. This is the first case report that describes the removal of hair tourniquet using a depilatory cream.

Review of cancer pain management in patients receiving maintenance methadone therapy.

Methadone is commonly used in the treatment of heroin addiction. Patients with a history of opioid misuse or on methadone maintenance therapy (MMT) with cancer often have difficult to manage pain. We studied 12 patients referred to the palliative care service with cancer pain who were on MMT. All had difficult to control pain, and a third required 5 or more analgesic agents. Two patients had documented ''drug-seeking'' behavior. Methadone was used subcutaneously as an analgesic agent in 1 patient. We explore why patients on MMT have difficult to manage pain, the optimal management of their pain, and the increasing role of methadone as an analgesic agent in cancer pain.