Monitoring of presterile disposable syringes and needles marketed in Pune

Out of hundred syringes and hundred needles (both presterile, disposable) tested, 41 syringes (41%) and 6 needles (6%) showed aerobic growth. Forty of the above syringes were tested simultaneously for fungi and anaerobes. Fungi isolated were 5.7% and no anaerobe was grown. Fifty glass syringes and fifty needles autoclaved in the departmental laboratory served as controls and did not show any growth. As a preventive measure, proper disposal of used disposable material should be made mandatory so that it does not find its way into the market. Or has the time come to switch back to the former conventional practice of using in house autoclaved articles?

A simple method for constructing microinjectrodes for reversible inactivation in behaving monkeys

A method for constructing a simple, durable injection-microelectrode (injectrode) is described. The injectrode can record neuronal activity, stimulate neuronal tissues, or inject substances locally through its tip. The injectrode is lightweight and is easy to construct from commercially available parts, and it can be used repeatedly for multiple recordings and injections. Since dura penetration can damage fragile electrode tips, a reliable method to pass the injectrode through an intact dura matter is described.

Manual cleaning of endoscopes: a comparison study of syringe versus suction methods using the endo-suction cleaning system

The manual syringe method of cleaning endoscopes involves numerous problems, including cross-infection, contamination, wasted time, and employee safety issues. This article describes the development of an alternative system by a nurse entrepreneur for endoscopic cleaning using a suction method. Scientific findings gathered over four years are presented supporting the efficacy and usefulness of this system, the Endo-Suction Cleaning System, also known as the PSK System.

Physician prescribing of sterile injection equipment to prevent HIV infection: time for action

Injection drug users, their sex partners, and their children are at high risk for acquiring HIV infection and other bloodborne diseases. The risk for disease transmission in the United States is partly the result of restricted access to sterile injection equipment. Physicians and pharmacists can play an important role in providing syringe access by prescribing and dispensing syringes to patients who use injection drugs and cannot or will not enter drug treatment Prescribing and dispensing injection equipment are ethical, clinically appropriate, and fully consistent with current public health guidelines on disease prevention. An analysis of the laws of the 50 U.S. states, the District of Columbia, and Puerto Rico finds that physicians in nearly all these jurisdictions may legally prescribe sterile injection equipment to prevent disease transmission among drug-using patients and that pharmacists in most states have a clear or reasonable legal basis for filling the prescriptions. Given these medical and legal findings, physicians may wish to take a larger role in improving access to sterile injection equipment by prescribing this equipment for their patients where this practice is legal, and by joining efforts to change the law where it poses a barrier.

Loss of factor VIII activity during storage in PVC containers due to adsorption

Recombinant factor VIII concentrates are stable when administered in a reconstituted form according to the manufacturer's specifications, and undiluted via infusion with syringe mini-pumps. However many Haemophilia centres administer recombinant factor VIII further diluted in intravenous fluids for greater ease of administration. To investigate the stability of recombinant factor VIII during administration as a diluted infusion, reconstituted factor VIII was stored in polyvinylchloride (PVC) mini-bags undiluted (146 IU mL-1) and at factor VIII concentrations of 10 IU mL-1 and 2 IU mL-1. After 48 h of storage at room temperature in PVC mini-bags, the recoveries of factor VIII activity were 41.9% of the initial activity for the undiluted (146 IU mL-1) product and 43.7% of the initial activity for factor VIII diluted to 10 IU mL-1. For factor VIII diluted to 2 IU mL-1, the amount of factor VIII activity remaining at 48 h was only 1.8% of the initial activity. In contrast, 100% of factor VIII activity was recovered after 48 h when undiluted reconstituted product (146 IU mL-1) was stored in a syringe. To investigate the mechanism of factor VIII activity loss during storage, factor VIII samples collected after 0, 3 and 48 h of storage were analysed by immunoblotting with factor VIII antibodies. No evidence of factor VIII proteolytic degradation during storage was found, however, large amounts of factor VIII antigen were recovered from the empty PVC mini-bags following elution with denaturing detergent. We conclude that clinically significant losses of factor VIII activity occur during storage in PVC mini-bags and that the loss of activity is most likely due to protein adsorption onto the plastic surface. This loss of factor VIII activity during storage in PVC containers may substantially affect the safety and potential cost savings of administering recombinant factor VIII by continuous infusion.

Insulin administration

The injection of insulin is essential for management of patients with type 1 diabetes and may be needed by patients with type 2 diabetes for intermittent or continuous glycemic control. The species and dosage of insulin used should be consistent, and the patient's injection technique should be reviewed periodically with the diabetes-care team. The effective use of insulin to obtain the best metabolic control requires an understanding of the duration of action of the various types of insulin and the relationship of blood glucose levels to exercise, food intake, intercurrent illness, certain medications, and stress; SMBG; and learning to adjust insulin dosage to achieve the individualized target goals established between the patient, family, and diabetes-care team.

Strategies for safe injections

In 1998, faced with growing international concern, WHO set out an approach for achieving injection safety that encompassed all elements from patients' expectations and doctors' prescribing habits to waste disposal. This article follows that lead and describes the implications of the approach for two injection technologies: sterilizable and disposable. It argues that focusing on any single technology diverts attention from the more fundamental need for health services to develop their own comprehensive strategies for safe injections. National health authorities will only be able to ensure that injections are administered safely if they take an approach that encompasses the whole system, and choose injection technologies that fit their circumstances.

Auto-disable syringes for immunization: issues in technology transfer

WHO and its partners recommend the use of auto-disable syringes, "bundled" with the supply of vaccines when donor dollars are used, in all mass immunization campaigns, and also strongly advocate their use in routine immunization programmes. Because of the relatively high price of auto-disable syringes, WHO's Technical Network for Logistics in Health recommends that activities be initiated to encourage the transfer of production technology for these syringes as a means of promoting their use and enhancing access to the technology. The present article examines factors influencing technology transfer, including feasibility, corporate interest, cost, quality assurance, intellectual property considerations, and probable time frames for implementation. Technology transfer activities are likely to be complex and difficult, and may not result in lower prices for syringes. Guidelines are offered on technology transfer initiatives for auto-disable syringes to ensure the quality of the product, the reliability of the supply, and the feasibility of the technology transfer activity itself.

Use of an illegal syringe exchange and injection-related risk behaviors among street-recruited injection drug users in Oakland, California, 1992 to 1995

OBJECTIVE

To determine factors associated with syringe and injection supply sharing among injection drug users (IDUs) in a community with an illegal underground syringe exchange program (SEP).

METHODS

From 1992 to 1995, semiannual cross-sectional samples of IDUs were recruited in Oakland, California. To account for multiple observations from the same individual, we used general estimating equations with logit transformations to determine factors associated with sharing syringes and other injection supplies.

RESULTS

1304 IDUs were interviewed; 684 (53%) returned for more than one interview. 2830 interviews were available for analysis. SEP use increased and syringe and supply sharing declined from 1992 to 1995 among study participants. In multivariate analysis, SEP users were less likely to share syringes than non-SEP users (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.46-0.72). SEP use was not significantly associated with the sharing of injection supplies (AOR = 0.85; 95% CI = 0.68-1.07). Syringe sharing and injection supply sharing were significantly less likely to occur among African American and HIV-positive IDUs.

CONCLUSIONS

These data suggest that illegal SEPs can be effective HIV prevention programs. Lower rates of syringe-based risk behaviors among African American and HIV-positive IDUs are encouraging.

A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution?

Our objectives were to estimate the annual number of injections by injection drug users (IDUs) in the United States of America, and to describe the potential role of pharmacists in providing IDUs with a sterile syringe for every injection. We estimated the number of annual injections by IDUs for the United States, selected U.S. states, and selected U.S. cities according to the following formula: number of injections per year = (number of IDUs) x (average number of injections per IDU per day) x 365. Data were obtained from published articles, personal communications with local experts, and selected national databases. We also reviewed published and unpublished studies of pharmacy kits, pharmacist attitudes, and pharmacist practices in the United States and abroad. Between 920 million and 1.7 billion injections by IDUs take place each year in the United States. We estimated 12 million injections per year in San Francisco and >80 million in New York City. A similar number of syringes would be needed to satisfy the goal of a sterile syringe for every injection. Pharmacy-based strategies, including the sale of kits for injection drug use, have provided sterile syringes to IDUs in Europe, Australia, and New Zealand. Modification of laws restricting syringe purchase and possession has led to marked increases in purchase of syringes from pharmacies and reductions in needle-sharing. In conclusion, large numbers of syringes would be required to provide a sterile syringe for every injection, but significant numbers of pharmacists seem to be willing to play a central role in syringe sale and distribution. Outreach programs should emphasize that using a sterile syringe for every injection is the optimal HIV prevention practice for IDUs who cannot or will not stop injecting. Pharmacy-based syringe sale or distribution has the potential to augment current efforts to prevent HIV infection in IDUs, their sex partners, and their children.

Enough sterile syringes to prevent HIV transmission among injection drug users in Montreal?

The HIV epidemic among injection drugs users in Montreal continues unabated. We wished to know whether sufficient syringes were being distributed to provide for the needs of injection drug users (IDUs) in Montreal. Using data from several sources, including the estimated number of active IDUs in 1994 and the injection frequency according to the drug consumed, we calculated the number of syringes required by IDUs. The number of syringes estimated was compared with the number of syringes distributed by needle exchange programs or sold in private pharmacies. Overall, we estimated that in 1994 about 10,683,000 syringes were required by the 10,000 IDUs in Montreal. Because about 338,000 syringes were distributed, <5% of the need was being met. The parameters in our analysis, particularly the number of IDUs in Montreal, drug use, and the frequency of injection, are subject to uncertainty. Nevertheless, because of the disparity between the small proportion of syringes distributed and the number required, it is unlikely that sufficient syringes are available to ensure access to clean needles and prevent HIV transmission. Measures should be taken to expand syringe distribution to Montreal IDUs.

Infusion devices: risks and user responsibilities

The Medical Devices Agency of the UK Department of Health continues to receive and investigate reports of incidents that arise from the use of infusion devices. In 1996, the Medical Devices Agency received some 4300 reports of incidents, over 400 of which were classified as infusion-, transfusion-, or dialysis-related. There is, however, a trend towards more active management of medical devices focusing on aspects such as purchasing, training, clinical use, and maintenance, and clearly, nursing staff have an important role in developing such policies. Also, nurses with the responsibility for setting up and overseeing infusions should be aware of some of the problems that can arise during routine use, as an awareness of potential hazards allows users to manage the risks more effectively. This article examines some of the risks associated with the use of infusion devices; in particular, problems that arise while loading the administration set or syringe into the pump, the risks of fluid free flow and syringe siphoning, and the risks from air embolism, flow rate accuracy and infusion pump pressure.

Using a value chain approach for effective decision making

Effectively managing costs in a healthcare environment may require taking a new look at how those costs are evaluated. The price of a product is not necessarily the most effective or efficient way of determining the actual cost. Using a value chain approach takes into consideration the functional costs of using a product as well, including both the "process" and "downstream" costs to an organization. In this article, Associate Professor Neil A. Wilner examines the differences between price and cost using a typical purchase in a healthcare environment.

Clinical immunogenicity and tolerance studies of liquid vaccines delivered by jet-injector and a new single-use cartridge (Imule): comparison with standard syringe injection. Imule Investigators Group

A new needleless jet-injector, Mini-Imojet, was developed that administers liquid vaccines from a single-use, pre-filled cartridge named Imule, which avoids the risk of cross-contamination. We conducted clinical trials in several settings in France and West Africa to compare the immunogenicity and tolerance of five vaccines (influenza vaccine, Vi capsular polysaccharide typhoid vaccine, tetanus toxoid vaccine, diphtheria-tetanus-whole cell pertussis vaccine, and inactivated hepatitis A vaccine) administered with the Imule system vs standard syringe technique. In each vaccine study, all subjects of either group were tested for serum antibody titres to calculate the geometrical mean titres and seroconversion rates after complete vaccination. Immediate local-reactions were noted after each injection, and local and general reactions were evaluated during a predetermined period of follow-up. When delivered by the Imule technique, all the administered vaccines were of equivalent or superior immunogenicity, compared to the syringe technique. The tolerance to vaccines injected by the Imule system was acceptable in all studies. The most frequently observed reactions were mild (e.g. minor bleeding, superficial papules, erythema and induration) and could be considered to be inherent to the injection technique. The technical and safety advantages of the Mini-Imojet/Imule system, compared to sterilizable, standard disposable or autodestruct syringes and to classical multi-dose vial jet-injectors, reinforces the interest of this new injection technique for collective immunizations.

Initial worker evaluation of a new safety syringe

A prospective evaluation of a new safety syringe requiring a one-step activation was carried out at the University of California, San Diego Medical Center. Only 59.5% of 390 syringes were activated, and user acceptance and satisfaction were unfavorable. The development of safety devices should incorporate passive activation and take end-user satisfaction into consideration.

Evaluation of syringes for ionized calcium measurements

Commercially available ready to use syringes (Radiometer, Sarstedt, Ciba-Corning and Portex), containing heparinate as an anticoagulant have been tested to evaluate the magnitude of induced preanalytical errors. Tonometered serum pools adjusted to four Ca2+ concentrations were sampled anaerobically.

MEASUREMENTS

Ca2+ and pH (ICA2 with 3 digits, Radiometer Medical A/S, Denmark; Heparin: anti-Xa factor activity on a chromogenic substrate. Results were expressed as means of 10 measurements and as percentages of the reference values. Sarstedt syringes, (Li-heparinate), yielded a negative bias (-3%). However for 0.5 or 1 mL samples the bias reached -4% to -6%. Radiometer syringes (QS50 and QS90; calcium titrated heparinate) demonstrated biases below -2%. The bias in the Ciba-Corning (Gas-Lyte) syringe was below 2%. Portex (Pulsator) syringes showed biases above +4% even for nominal sampling volumes. All syringes (except Pulsator) released anticoagulant amounts corresponding to the expected values. Radiometer and Ciba-Corning were the only recommendable devices.

Fluid delivery from infusion-pump syringes

Fluid-delivery rates of five small-volume infusion-pump syringes were compared. The study consisted of a comparison of the infusion-pump syringes in their respective infusion pumps (1) set for continuous delivery at 1 mL/hr, (2) set for continuous delivery at 3 mL/hr, and (3) set to deliver 1-mL bolus volumes during continuous delivery at 4 mL/hr. The Life-care prefilled 30-mL syringe (Abbott), the DBL 30-mL syringe no. 770205 (DBL Inc.), and the Pump-Jet 30-mL syringe no. 1931 (International Medication Systems) were tested in the Lifecare PCA Plus II infusion pump no. 4100 (Abbott). The 30-mL Pump-Jet syringe no. 1911 (International Medication Systems) and the DBL 30-mL syringe no. 709700 (DBL Inc.) were tested in the Stratofuse PCA infusion pump (Baxter). The infusion pumps were set to deliver fluid continuously at 1 mL/hr for 30 hours, and the solutions were collected separately and weighed. The procedure was repeated with the infusion rate set at 3 mL/hr for 10 hours. For the third part of the study, each syringe was tested to deliver 1-mL boluses with 0, 5, 15, and 25 mL removed from the syringe. The solutions were collected and weighed before and after each bolus was delivered. The volume of solution collected was calculated by using the specific gravity of the solution. The syringes delivered significantly different volumes during the first hour of infusion at both the 1- and 3-mL/hr rates. Differences also existed across time for most of the syringes. Bolus volumes varied greatly after infusion of 0 or 5 mL of fluid but were acceptable for the remainder of the infusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety, efficacy, acceptability of a pre-filled insulin pen in diabetic patients over 60 years old

The aim of the study was to evaluate safety, efficacy and acceptability of a pre-filled insulin pen device (NovoLet) in diabetic patients over 60 years old already treated with insulin administered with conventional syringes. After a run-in period of 2 weeks, 60 patients participated in a randomized cross-over study with two 6-week treatment periods using the insulin pen or conventional syringes. Insulin regimens did not change during the study. Hypoglycaemic episodes did not differ significantly between both kinds of treatment and no severe hypoglycaemia was registered. HbAlc (%) was (mean +/- S.D.) 7.7 +/- 1.2 and 7.9 +/- 1.1 during pen and syringe treatment, respectively. Blood glucose profiles were similar during both treatment modalities except for pre-lunch blood glucose values (mmol/l) lower during pen treatment (8.7 +/- 2.9 vs. 9.2 +/- 2.7, P < 0.01). The insulin dose (U/day) was 31.9 +/- 8.9 (pen) and 32.3 +/- 9 (syringe). 54 patients found the functioning of the insulin pen easy to understand and preferred it for future treatment because the conditions of insulin administration are faster and easier than with conventional syringes. We concluded that the pre-filled insulin pen is safe, efficacious and is highly accepted in over 60 years old diabetic patients.

Getting the most out of low-dose syringe prefilling of a high-cost biotechnology agent

The recent increased usage of high-cost biotechnology agents has placed a tremendous impact on the hospital pharmacy budget. One approach in improving cost containment is to minimize waste during the preparation of these agents. This is particularly practical and possible in the process of low-dose syringe repackaging of Sargramostim (GM-CSF) used for the treatment of neutropenia. In search of ways to reduce waste, this study looked into the dos and don'ts of repackaging this agent in syringes. Decreased waste is very significant if GM-CSF is properly reconstituted with bacteriostatic water for injection and if a syringe equipped with a permanently attached needle is used. Another 10% of the solution from each vial could be saved if the solution is withdrawn with a technique involving the vial in a right-side-up position.

Accuracy and precision of low-dose insulin administration

OBJECTIVE

To determine the lowest dose of concentrated (U100) insulin that can be reproducibly delivered.

METHODS

A telephone survey was used to determine current practices in major pediatric hospitals regarding the administration of low doses of concentrated insulin. A sensitive gravitometric technique was used to determine the error in measurement of low doses of U100 insulin by pediatric nurses and parents of diabetic children.

RESULTS

A telephone survey revealed that doses as low as 0.5 or 1.0 U (5 to 10 microL) are routinely administered in pediatric hospitals. In our study of pediatric nurses, attempts to deliver 0.5, 1.0, and 2.0 U resulted in delivered doses of 0.975 +/- 0.315, 1.638 +/- 0.376, and 2.153 +/- 0.435 U (mean +/- standard deviation of the mean), respectively. The use of 0.3-mL syringes compared to 0.5-mL syringes did not improve accuracy or precision. Taken as a group, parents of children with diabetes were more accurate (mean delivered dose of 1.063 +/- 0.276 for the 1-U dose), but the individual means ranged from 0.641 to 1.300 and coefficients of variation ranged from 5% to 33%. Only three of the seven parents could deliver 1.0 U with acceptable precision and accuracy.

CONCLUSIONS

When currently available syringes are used, insulin injections of less than 20 microL (2 U of U100) have an unacceptably large error. It is recommended that, in the inpatient setting, diluted insulin be used if the prescribed dose is less than 2.0 U.

Quality testing of medical needles--laboratory and practice

Tip deformities as small as 10 mum on cannulae can cause unnecessary pain to patients. The only way of preventing these deformed cannulae from reaching patients is to test every cannula at the manufacturing stage. Clinical and laboratory tests carried out by the company compare handling and trauma caused by medical cannulae with technical parameters for manufacturing and testing. This article discusses the results of these tests, which the author found verified that the properties of medical cannulae can be evaluated by measuring the penetration load piercing a skin substitute. The discovery of tip deformities with clinical significance led to the development of specially designed equipment that detects the presence of deformities by using the noise made by a deformed cannula penetrating a foil.

Stability of blood gases, electrolytes and haemoglobin in heparinized whole blood samples: influence of the type of syringe

The alterations of blood gases, pH, electrolytes and haemoglobin during 45 min storage in ice-water were measured in 6 types of syringes (1 glass and 5 plastic syringes, among these 3 "blood gas samplers"). It was confirmed that pO2 generally is not stable in plastic syringes. However, considerable differences among plastic syringes were found in this respect, the smallest increase occurring in an ordinary 2 ml syringe for injections and the greatest in one of the special blood gas samplers. Due to the "buffering effect" of deoxyhaemoglobin, the alterations of pO2 are smaller in the hypoxaemic than in the normoxaemic range. Relevant pO2 alterations in plastic syringes are demonstrable after 20 minutes. It is concluded that blood collected in plastic syringes must be analysed within 15 min after sampling, otherwise glass syringes should be used for blood collection. Deviations of pCO2, pH and electrolytes are described in detail. In general, they are due to sampling rather than to storage, and can be effectively minimized by a small dead space of the syringe and by use of an electrolyte-balanced heparin solution. The danger of erroneous haemoglobin measurements due to unequal resuspension of the red cells after storage is pointed out.

Effect of two different syringes on syringe driver function

A laboratory investigation into the effect of two different syringes on the performance of a syringe driver was undertaken in order to assess accuracy of delivery, occlusion-alarm delay time and the effect of incorrectly coding the device for the syringe in use. Results indicated that accuracy of delivery was of the order of -1%/h for both syringe types at an infusion rate of 5 ml/h. Clinically and statistically significant differences in the occlusion-to-alarm time were found between syringes and between infusion rates. At 99.9 ml/h lag time was about 30 seconds for both syringes, whereas at 5 ml/h this was 667 seconds for one syringe and 903 seconds for the other. Incorrect coding of the driver for the syringe in use, resulted in a significant change in the accuracy of delivery at an infusion rate of 5 ml/h. Similarly, incorrect coding resulted in changes in the occlusion-alarm time. These results carry significant pharmacological implications for the clinical situation.