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  • Associate Professor of Pharmacy Practice, Butler University, College of Pharmacy and Health Sciences
  • Director of Ambulatory Pharmacy Services, Community Health Network, Indianapolis, Indiana


It is also used as a disease modifying drug and is often referred to heart attack signs and symptoms discount aceon 4 mg amex as a steroid-sparing agent or an immunomodulator hypertension over 55 purchase 2 mg aceon with amex. Methotrexate uses in this protocol are limited to: Rheumatology Commonly used as a first line treatment for active rheumatoid arthritis (licensed) printable blood pressure chart uk buy cheap aceon 8 mg line. Neurology Used as a second-line therapy (unlicensed) for a range of neurological disorders including; myasthenia gravis hypertension of chronic kidney disease is medicated with buy cheapest aceon, inflammatory myopathies and neuropathies, vasculitis and other immunemediated central and peripheral nervous system diseases Gastroenterology Inflammatory bowel disease (unlicensed). It is reserved for patients who fail to respond to or are intolerant of thiopurines (azathioprine or mercaptopurine). Respiratory 2 Interstitial lung diseases, sarcoidosis and pulmonary vasculitis (unlicensed uses). Ophthalmology Inflammatory eye conditions (unlicensed) o Indicated for scleritis, either idiopathic or in the context of rheumatoid arthiritis, vasculitis or mixed connective tissue diseases the commonest indication is in children suffering from persistent sight-threatening uveitis. Paediatrics Juvenile Idiopathic Arthritis, Juvenile Systemic Lupus Erythematosus, Juvenile Dermatomyositis, Uveitis, Vasculitis and Other Connective tissues such as Scleroderma (localised & systemic) and Sarcoidosis. Patients planning on becoming pregnant or who think they are pregnant should be seen by the specialist. Precautions Elective surgery Methotrexate can be continued (caution for early detection of infection and complications). Folic acid should be prescribed at a dose of 5 mg weekly, to be given 4 days after methotrexate. Folic acid should be prescribed routinely at a dose of 5mg once weekly, to be taken 4 days after methotrexate. Inflammatory bowel disease Usual dose: 15 to 25 mg weekly orally or subcutaneously. The specialist may decide to increase the dose of folic acid if side effects occur. Folic acid should be prescribed routinely at a dose of 5mg weekly, to be taken 4 days after methotrexate. In exceptional circumstances, the Neurologist may advise higher doses up to 25 mg, If the oral route is not effective or tolerated, subcutaneous administration may be considered. It is usually given on the same day each week, but on occasions there may be an agreement to give a dose a day or two either side to help compliance. It may be used to reduce side effects at a dose of 15mg per week, to be given 4 days after the methotrexate is recommended (not on the same day as methotrexate). If it is being used in an unlicensed indication this must be explained to patient. The patient will be counselled by the consultant not to start the injections before they have received training by the specialist nurse team. Once the patient has collected their first supply of medication, they can then phone the advice line to arrange an injection technique training appointment. If it is not possible for patient or parent/carer to administer the injections, alternative arrangements will be made by the Advanced Nurse Practitioners. Disposal of sharps Cytotoxic sharps boxes (purple) will be provided by the hospital specialist nurse on initiation of treatment when attending for the self-administration training. Following that, based on clinical judgement, consider reducing dermatology and frequency of monitoring to every 2 to 3 months. Thereafter Inflammatory bowel bloods should be checked every 2 to 3 months unless there are clinical disease signs of over immunosuppression. Unexplained fall in albumin Withhold and speak to specialist Usually improves over time. If troublesome for adults consider: Increasing the dose of folic acid to 5 mg daily up to 6 days a week omitting on the day methotrexate is taken. Nausea and/or vomiting For children consider: Increase folic acid to 1-5mg, 3 days a week. If severe Mouth ulcers, mucositis despite extra folic acid stop methotrexate and refer to a specialist for advice. Withhold treatment, arrange chest Otherwise unexplained X-ray and discuss urgently with consultant. Discuss with paediatric by fever/sweats) rheumatologist if an atypical presentation or persists > 2 weeks without preceding infection. Patients are advised not to take the dose if more than 24-72 hours late (this depends on speciality so follow advice of specialist) but take as normal the following week. Sulphonamides Fansidar Under specialist advice this combination is not contraindicated. Patients co-prescribed ciclosporin with methotrexate should initially be Ciclosporin re-stabilised by the specialist as it can increase methotrexate toxicity. Remember for vaccines paediatric patients, Fluenz Tetra (nasal flu vaccine) is live so must not be used. Information from personal communication with specialist gastroenterologists, 2006. Methotrexate starting doses: Personal communication from specialist rheumatologists, May 2010. Concomitant leflunomide therapy in patients with active rheumatoid arthritis despite stable doses of methotrexate: A randomized, double blind, placebo-controlled trial. Evaluate cardiac • For Injection: 150 mg lyophilized powder in a single-dose vial for function prior to and during treatment. The incidence and severity was highest in patients receiving Herceptin with anthracycline-containing chemotherapy regimens. Evaluate left ventricular function in all patients prior to and during treatment with Herceptin. Discontinue Herceptin treatment in patients receiving adjuvant therapy and withhold Herceptin in patients with metastatic disease for clinically significant decrease in left ventricular function [see Dosage and Administration (2. Infusion Reactions; Pulmonary Toxicity Herceptin administration can result in serious and fatal infusion reactions and pulmonary toxicity. Discontinue Herceptin for anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome [see Warnings and Precautions (5. Embryo-Fetal Toxicity Exposure to Herceptin during pregnancy can result in oligohydramnios and oligohydramnios sequence manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death. Advise patients of these risks and the need for effective contraception [see Warnings and Precautions (5. Improper assay performance, including use of suboptimally fixed tissue, failure to utilize specified reagents, deviation from specific assay instructions, and failure to include appropriate controls for assay validation, can lead to unreliable results. Adjuvant Treatment, Breast Cancer Administer according to one of the following doses and schedules for a total of 52 weeks of Herceptin therapy: During and following paclitaxel, docetaxel, or docetaxel/carboplatin: • Initial dose of 4 mg/kg as an intravenous infusion over 90 minutes then at 2 mg/kg as an intravenous infusion over 30 minutes weekly during chemotherapy for the first 12 weeks (paclitaxel or docetaxel) or 18 weeks (docetaxel/carboplatin). As a single agent within three weeks following completion of multi-modality, anthracycline-based chemotherapy regimens: • Initial dose at 8 mg/kg as an intravenous infusion over 90 minutes • Subsequent doses at 6 mg/kg as an intravenous infusion over 30fi90 minutes every three weeks [see Dosage and Administration (2. Metastatic Treatment, Breast Cancer • Administer Herceptin, alone or in combination with paclitaxel, at an initial dose of 4 mg/kg as a 90-minute intravenous infusion followed by subsequent once weekly doses of 2 mg/kg as 30-minute intravenous infusions until disease progression. Metastatic Gastric Cancer • Administer Herceptin at an initial dose of 8 mg/kg as a 90-minute intravenous infusion followed by subsequent doses of 6 mg/kg as an intravenous infusion over 30–90 minutes every three weeks until disease progression [see Dosage and Administration (2. Subsequent Herceptin maintenance doses should be administered 7 days or 21 days later according to the weekly or three-weekly schedules, respectively. If the patient has missed a dose of Herceptin by more than one week, a re-loading dose of Herceptin should be administered over approximately 90 minutes (weekly schedule: 4 mg/kg; threeweekly schedule: 8 mg/kg) as soon as possible. Subsequent Herceptin maintenance doses (weekly schedule: 2 mg/kg; three-weekly schedule 6 mg/kg) should be administered 7 days or 21 days later according to the weekly or three-weekly schedules, respectively. Use appropriate aseptic technique when performing the following reconstitution steps: • Using a sterile syringe, slowly inject the 20 mL of diluent into the vial containing the lyophilized powder of Herceptin, which has a cake-like appearance. The reconstituted vial yields a solution for multiple-dose use, containing 21 mg/mL trastuzumab. The solution should be free of visible particulates, clear to slightly opalescent and colorless to pale yellow. Dilution • Determine the dose (mg) of Herceptin [see Dosage and Administration (2. Calculate the volume of the 21 mg/mL reconstituted Herceptin solution needed, withdraw this amount from the vial and add it to an infusion bag containing 250 mL of 0. Use appropriate aseptic technique when performing the following reconstitution steps: • Using a sterile syringe, slowly inject 7. The reconstituted vial yields a solution for single-dose use, containing 21 mg/mL trastuzumab. If not used immediately, store the 0 0 0 0 reconstituted Herceptin solution for up to 24 hours at 2 C to 8 C (36 F to 46 F); discard any unused Herceptin after 24 hours.

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In tauopathyfifrontotemporal dementia mice arrhythmia nursing diagnosis purchase online aceon, both drugs were neuroprotective blood pressure medication questions buy cheapest aceon and aceon, rescued memory deficits and reduced hip pocampal atrophy hypertension 2 symptoms 2 mg aceon with amex. These compounds therefore represent potential new diseasefimodifying treatments for dementia blood pressure 8050 discount aceon 2 mg without a prescription. There are no available observational data suggesting that trazodone reduces risk of dementia but some data that suggest important adverse outcomes in older people. These include: Semagacestat, a fisecretase inhibitor;139 the trials including 3000 patients were dis continued in 2010 because of the absence of improvement in cognition in the study group and worsening cognition at higher doses compared to controls. It is caused by ischaemic dam age to the brain and is associated with cognitive impairment and behavioural disturbances. The management options are currently very limited and focus on control ling the underlying risk factors for cerebrovascular disease. The Cochrane review for rivastigmine in vascular cognitive impairment found some evidence of benefit, however the conclusion was based on one large study and adverse effects with rivastigmine led to withdrawal in a significant proportion of patients. Characteristic symptoms are dementia with fluctuation of cognitive ability, early and persistent visual hallucinations and spontaneous motor features of parkinsonism. Falls, syncope, tran sient disturbances of consciousness, neuroleptic sensitivity and hallucinations in other modalities are also common. The sample sizes of most trials were very small Prescribing in older people 551 Table 6. Early evi dence suggests that multifactorial interventions may have potential to prevent or delay the onset of dementia. Dementia: supporting people with dementia and their carers in health and social care. Widely spread butyrylcholinesterase can hydrolyze acetylcholine in the normal and Alzheimer brain. Selectivity of cholinesterase inhibition: clinical implications for the treatment of Alzheimer’s disease. Memantine monotherapy for Alzheimer’s disease: a systematic review and metafianalysis. Ebixa 5mg/pump actuation oral solution, 20mg and 10 mg Tablets and Treatment Initiation Pack. A riskfibenefit assessment of dementia medications: systematic review of the evidence. Efficacy and safety of cholinesterase inhibitors in Alzheimer’s disease: a metafianalysis. Discontinuation, efficacy, and safety of cholinesterase inhibitors for alzheimer’s disease: a metafianalysis and meta regression of 43 randomized clinical trials enrolling 16 106 patients. Associations of acetylcholinesterase inhibitor treatment with reduced mortality in Alzheimer’s disease: a retrospective survival analysis. The effectiveness and costfieffectiveness of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease (review of Technology Appraisal No. Donepezil improves cognition and global function in Alzheimer disease: a 15fiweek, doublefiblind, placeboficontrolled study. A 24fiweek, doublefiblind, placeboficontrolled trial of donepezil in patients with Alzheimer’s disease. Efficacy and safety of rivastigmine in patients with Alzheimer’s disease: international randomised controlled trial. A sixfimonth doublefiblind, randomized, placeboficontrolled study of a transdermal patch in Alzheimer’s disease – rivastig mine patch versus capsule. Rivastigmine patch in Chinese patients with probable Alzheimer’s disease: a 24fiweek, randomized, doublefiblind parallel group study comparing rivastigmine patch (9. Absolute bioavailability and safety of a novel rivastigmine nasal spray in healthy elderly individuals. Efficacy and safety of galantamine in patients with mild to moderate Alzheimer’s disease: multicentre randomised con trolled trial. The place of memantine in the treatment of Alzheimer’s disease: a number needed to treat analysis. The severe impairment battery: concurrent validity and the assessment of longitudinal change in Alzheimer’s disease. The comparative efficacy and safety of cholinesterase inhibitors in patients with mildfitofimoderate Alzheimer’s disease: a Bayesian network metafianalysis. A longitudinal study of Alzheimer’s disease: measurement, rate, and predictors of cognitive deterioration. Efficacy and safety of donepezil over 3 years: an openfilabel, multicentre study in patients with Alzheimer’s disease. Openfilabel, multicenter, phase 3 extension study of the safety and efficacy of donepezil in patients with Alzheimer disease. Clinical practice with antifidementia drugs: a revised (third) consensus statement from the British Association for Psychopharmacology. Tolerability of switching from donepezil to memantine treatment in patients with moderate to severe Alzheimer’s disease. Patterns of cholinesterasefiinhibitor use in the nursing home setting: a retrospective analysis. Safety and tolerability of oncefidaily versus twicefidaily memantine: a randomised, doublefiblind study in moderate to severe Alzheimer’s disease. Clinical recommendations for the use of donepezil 23 mg in moderatefitofisevere Alzheimer’s disease in the AsiafiPacific region. Memantine extended release (28 mg once daily): a review of its use in Alzheimer’s disease. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. Tolerability of memantine in combination with cholinesterase inhibitors in dementia therapy. Combination therapy with cholinesterase inhibitors and memantine for Alzheimer’s disease: a systematic review and metafianalysis. Lack of pharmacokinetic or pharmacodynamic interaction between memantine and donepezil. Rationale for combination therapy with galantamine and memantine in Alzheimer’s disease. Factors associated with serious adverse reactions to cholinesterase inhibitors: a study of spontaneous reporting. Safety and tolerability of rivastigmine transdermal patch compared with rivastigmine capsules in patients switched from donepezil: data from three clinical trials. Switching from oral cholinesterase inhibitors to the rivastigmine transdermal patch. Randomized, doublefiblind, parallelfigroup, 48fiweek study for efficacy and safety of a higherfidose rivastigmine patch (15 vs. A review comparing the safety and tolerability of memantine with the acetylcholinesterase inhibitors. Adverse effects associated with the use of donepezil in general practice in England. Adverse drug reactions reported with cholinesterase inhibitors: an analysis of 16 years of individual case safety reports from vigibase. Cholinesterase inhibitors and cardiovascular disease: a survey of old age psychiatrists’ practice. Cholinesterase inhibitors and hospitalization for bradycardia: a populationfibased study. Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a populationfibased cohort study. The Assessment of Cardiac Status Before Prescribing Acetyl Cholinesterase Inhibitors for Dementia. Which cholinesterase inhibitor is the safest for the heart in elderly patients with Alzheimer’s diseasefi Comparative cardiovascular safety of dementia medications: a crossfinational study.

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Inflamed heart attack sam tsui chrissy costanza of atc purchase aceon with paypal, itchy ears without growth of microorganisms most likely indicates an allergic underlying etiology blood pressure 45 year old male buy genuine aceon online. Here heart attack 911 discount 4 mg aceon fast delivery, caution is warranted arteria epigastrica superficialis buy aceon 2 mg, as the infection has gone beyond just “surface overgrowth” and is heading towards a soft-tissue infection. Caution here – more difficult to predict susceptibility and empirically choose an antibiotic. However, if the otitis is resistant to initial treatment or recurrent, especially if rods are present, it is clearly indicated. Remember, too, that this test reports susceptibility of organisms to tissue or plasma concentrations of antibiotics, and therefore is mostly relevant to choose a systemic antibiotic for more severe cases. The concentration of antibiotics in otic preparations is typically hundreds of times that attainable in plasma, so an “intermediate” result for an antibiotic means that the drug will probably work if used topically. More than 80% of “everyday” otitis in cats involves Malassezia, Staphylococcus, Pasteurella, or coliforms. Staph and Pasteurella organisms almost always have broad susceptibility, and any of the common aminoglycoside antibiotics (such as gentamicin) should be effective. Bear in mind that this antibiotic is made less effective by exudate in the ear canal, so the ear must be clean to use it! Remember that fusidic acid is effective against Gram-positive organisms only, thus in ears, it should be used only if cytology indicates cocci. This antibiotic is similar to chloramphenicol; it is best used for otitis where cocci are present, as its activity against rod bacteria is highly variable and it is completely ineffective against Pseudomonas. One misconception is that if yeast otitis is recurrent, it is a failure of antifungal treatment. Rather, this clinical situation reflects a continuing underlying inflammatory ear condition, usually allergy, and calls for corticosteroids rather than a different antifungal! Almost all topical ear therapeutics contain a corticosteroid, usually a low to moderate potency drug and all are reasonably equivalent. Newer use of the “soft” steroids such as hydrocortisone aceponate or mometasone have the possibility of providing good antiinflammatory action with less chance of adverse effects. It reduces physical narrowing of the canal, reduces cerumen secretion, and therefore makes it much more difficult for organisms to grow. Ototoxicity varies by species, and information is sparse in cats, though cats seem to be more prone to ototoxicity than dogs. Some authors recommend avoiding topical treatment of cat ears, period – in part due to difficulty of application, and in part relating to the increased possibility for ototoxicity. There is no question that debris, cerumen, and pus in the ear canal creates food, moisture, and “hiding places” for growth of microorganisms, impedes flow and efficacy of topical preparations, and inactivates some antimicrobials. Depending on how severe and sore the ear is, this may be done with or without sedation. Using mild, pH neutral detergent or solvent solutions is best in an inflamed, sore ear. Demonstrate to the owner how to hold the pinna up, instill the cleaner into the ear canal without touching the tip to the pinna, massage the canal to loosen and solubilize the debris, and then wipe or blot it out with a gauze pad around a finger. Repeat until the material being blotted is no longer colored or laden with debris. There are two reasons that “cleaning solutions” are used: (1) to physically soften, dissolve, and remove debris; and (2) to leave an antimicrobial ingredient in the ear, to help with limiting growth of organisms. Once the ear has healed, and the goal is more the antimicrobial action, you can think more about the antiseptic ingredient. The latter is especially important in long-term “preventive maintenance” if it will be required. My bias is to recommend no cleaning for the first 3-4 days, until the ear is more comfortable. The 5 Causes of Recurrent Otitis When otitis is recurrent, there are really only 5 reasons why this situation exists. Note that there might be just one reason, or any combination of: • An antimicrobial-resistant organism (most often, Pseudomonas) • Ear pathology causing persistent stenosis or occlusion; this includes stenosis from edema, hyperplasia, or scarring; and occlusion from the same or from a mass lesion. In a young cat, the obvious example is a nasopharyngeal polyp; in older cats, a neoplasm. Typically, maintenance therapy will consist of: • Regular cleaning at home (every 1-2 weeks), with an ear cleaner that contains an antimicrobial ingredient. This both removes debris, and makes the ear inhospitable to further growth of organisms. As an alternative, the author routinely uses a solution of 1 mg/ml dexamethasone in propylene glycol. To formulate this, mix one part of propylene glycol with 1 part of dexamethasone injection (the 2 mg/ml product). This is an inexpensive and effective longer-term treatment for inflammatory ear disease. It is also possible to use CortavanceO topical spray off-label for this purpose; most authors recommend 0. Followup information was available for 9 cats – and 8 of these resolved without relapse. The author suggests a 3-step approach, in which the first step is to identify obvious causes such as parasites; step 2 is to eliminate secondary complications such as bacterial and yeast skin infections; and step 3 is to carefully observe the remaining clinical signs. This in combination with the patient’s history often helps guide further diagnostic evaluation to find the true cause of the itch. Identify the Obvious Things the first step is to consider common and usually obvious things like parasites. Extinguish the Fires Most patients with pruritic skin disease of any severity have their primary disease complicated by one or more “layers” of secondary complications. This often makes it impossible to see what the true nature of the primary disease is. Therefore, it is critically important as a next step to identify and treat any and all possible secondary complications. These can be identified by physical examination of the skin, in association with skin cytology where necessary. All of these lesions, and in addition any draining or ulcerative lesions, should be assessed by cytology, looking for typical cocci organisms. If present, treat with appropriate antibiotic (or topical chlorhexidine) for 4 weeks. If the pet has been treated with multiple courses of antibiotics in the past, a culture and susceptibility test is recommended to detect multi-drug resistant staphylococci. With chronic disease, there is lichenification and hyperpigmentation to form an appearance of “elephant skin. Remember that the condition is actually a hypersensitivity reaction to the yeast, so the number of yeast may be very small. For initial treatment, the author prefers oral ketoconazole (or any other oral azole), 5-10 mg/kg/d for 2-4 weeks. This is a common secondary problem in many dogs and contributes greatly to the patient’s discomfort. It is acceptable to use antihistamine medications here – they won’t interfere with resolution of infection, may cause slight sedation to help the pet sleep, and give some ‘psychological’ comfort to the owner. Following this, the patient’s response to infection control is a valuable clue to the underlying disease and will aid greatly in planning logical diagnostic evaluation for each patient. We can then propose 4 groups of possible underlying causes, depending on response. Here, application of “Favrot’s Criteria” to make a clinical diagnosis of canine atopic dermatitis may apply. Possible diagnoses to consider include parasitism, adverse food reactions (some of which include lesions), primary seborrhea, and dermatophytosis. Diagnostic steps in this case might include repeated skin scrapings and trichogram, empirical treatment for scabies mites, a hypoallergenic diet trial, and fungal culture. Along with these differential diagnoses, the possibility of inadequate initial treatment should be considered. It is also possible that the diagnosis of pyoderma was not correct—non-pyoderma pustular diseases like pemphigus foliaceus may be present. Bacterial culture and susceptibility testing, fungal culture, and skin biopsy might be considered with this response pattern. In a younger dog, many authors believe that very early allergic disease can first manifest as increased susceptibility to skin infections, without little or no pruritus remaining after infection control.

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Because this is not always feasible in patients with large burn injuries who require long-term vascular access pulse pressure and blood pressure order aceon 2mg amex, frequent change of the catheter may be atempted to blood pressure chart when to go to the hospital discount aceon online master card decrease risk of infection arteria definicion buy line aceon. Hydrotherapy is used routinely in some facilities; however it has been associated with outbreaks hypertension and pregnancy order 2mg aceon free shipping, particularly among patients with large burns. Disinfection protocols generally describe rinsing the tanks or equipment with a solution of sodium hypochlorite afer each use. Behavioural Health Background Behavioural health care provides prevention, intervention, and treatment services in the areas of mental health, substance abuse, developmental disabilities, and sexuality. Infection risks Geriatric patients in behavioural health ofen acquire urinary tract and upper respiratory infections. Skin and sof tissues are also frequent sites of infection in this specific population. Sta should be aware of their immune status and practice standard precautions/routine practices. Those who work with children should be vaccinated for typical childhood illnesses. An inpatient infiuenza and pneumococcal immunisation program should be considered for adults. Special consideration should be given to the clothing of patients with incontinence, wound infections, or lesions, and suspected or confirmed cases of scabies or lice. Procedures with regard to lice and scabies should include identification of illness, monitoring for transmission, treatment (includes sta monitoring of the application of treatment) and follow-up, and housekeeping procedures. Patients can be provided with a caddy or basket in which to keep personal toiletry items if they share a bathroom. Disposable paper mats for individual shower use protect the patient from transmission of athlete’s foot (Tinea pedis). Disposable razors for shaving should be provided and discarded afer use in an appropriate sharps container. If electric shavers are provided, a protocol for cleaning and disinfecting the shaver afer each use is needed. For electroconvulsive therapy, there should be procedures for hand hygiene, use of gloves, and the cleaning and disinfection of equipment. Reusable items such as bite blocks and laryngoscope blades require high-level disinfection. Ambulatory/Community Care Background Ambulatory/community care setings provide health care to patients who do not remain overnight; examples include physician’s surgeries, clinics, dental surgeries, diagnostic treatment centres, and physical and occupational therapy centres. Definitions used in hospitals, long term care facilities, or home care may be adapted. Audits consisting of a standard list of criteria that are checked at each site are commonly used. The chief risk is spread of infection by an airborne or droplet route; outbreaks of respiratory viruses have been reported in these setings. Burkholderia cepacia bacteraemia and hepatitis B and C infections have been atributed to reuse of needles and syringes and use of multidose vials of medication. Additional activities in these setings focus on communicable diseases, respiratory hygiene, toys, and instruments/devices. Patients should be assessed as soon as possible for signs and symptoms of potentially communicable illnesses, particularly productive cough, diarrhoea, undiagnosed rash, bleeding, and wound or eye drainage. Patients with these conditions should be placed in a separate room as soon as possible. Respiratory hygiene / respiratory etiquete measures are designed to limit droplet spread. Patients presenting with cough or respiratory symptoms should be provided with tissues or surgical masks and instructed to cover coughs and sneezes with a tissue and where to safely dispose of tissues. Patients should be reminded to clean their hands afer a cough or sneeze and a container of alcohol based hand rub should be available. Patients with suspected or known tuberculosis, chickenpox, measles, mumps, rubella, or bacterial meningitis should wear a surgical mask and be placed in a separate room with the door closed and a sign placed on the door to inform sta of necessary precautions. Afer a patient with suspected tuberculosis leaves an examination room, close the door and allow the room to ventilate before using it again. All re-usable instruments and medical devices require writen procedures for cleaning and disinfection or sterilisation. The use of safer medical devices designed to reduce the risk of needle-stick injuries should be evaluated. Immunocompromised Populations Background the severe neutropenia of treatment regimens and certain underlying diseases, coupled with invasive devices and procedures which bypass the physical barriers to infection, result in a high frequency of infection in these patients. In addition, illnesses such as acquired immune deficiency syndrome, place the patient at risk for infection. Because of defects in immunity, environments and activities that would be safe for patients with intact immune systems present hazards for these patients. Infection risks There are four broad categories of risk factors that predispose the immune compromised host to infection: 1) granulocytopenia; 2) immune system defects; 3) destruction of protective barriers. The oral cavity is a reservoir for microorganisms capable of causing life-threatening infection. Any severe mucositis experienced by patients predisposes the spread of these microorganisms into the bloodstream. Patients and family members, as well as healthcare workers, should be taught the importance of hand hygiene. Screening programs for communicable infections in visitors and sta are essential, especially during the appropriate “seasons” for certain illnesses. Every efiort should be made to restrict from direct patient care activities all healthcare workers with infections that may be spread to immunocompromised patients. However, there are insuficient data to provide recommendations regarding the use of these additional protective precautions. Dust accumulation should be prevented with daily cleaning of frequently touched horizontal surfaces. However, cleaning methods that generate dust, such as dry dusting and mopping, should be avoided. Doors to patient rooms should remain closed while any vacuuming takes place nearby. Several studies have suggested an association between aerosols from showerheads and aerators and outbreaks of Legionella, Acinetobacter, and even Aspergillus sp. All toys are to be cleaned and disinfected regularly and when visibly soiled or mouthed. Construction and renovation may result in an increased risk for healthcare-associated invasive mould infection, particularly aspergillosis. Whenever possible, immunocompromised patients should avoid construction or renovation areas. Containment measures necessary to protect at-risk populations from dust include adequate barriers with air-tight seals and negative pressure inside a construction site. International Perspectives the epidemiology of infectious diseases and antibiotic resistance varies by geographical area. Despite these difierences, the principles should basically remain the same; that is, recognise that the patient is at increased risk for certain types of infection and minimise that risk to the extent possible. However, thoughtful adaptation of these practices may be necessary in certain types of setings or with certain groups of patients. Food Safety: Gastroenteritis and FoodBorne Disease in Elderly People Living in Long-Term Care. Exogenous endoscopy-related infections, pseudo-infections, and toxic reactions: clinical and economic burden. Deviceassociated nosocomial infection surveillance in neonatal intensive care using specified criteria for neonates. Infection prevention and control in health care facilities where hematopoietic cell transplantation recipients are treated. Management of an outbreak of Clostridium difficile-associated disease among geriatric patients. Requirement for infrastructure and essential activities of infection control and epidemiology in outof-hospital setings: a consensus panel report. Standardized infection surveillance in long-term care: interfacility comparisons from a regional cohort of facilities.