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The presence of large number of psychrophilic bacteria in refrigerated foods such as dairy products, meat, poultry and sea food may reflect growth of initial population during storage and /or massive contamination at some point prior to or during refrigerated storage. Thermoduric organisms are those organisms which will survive so significant measure of heat treatment 350. The thermophilic organisms not only survive the heat treatment but also grow at the elevated temperature. Thermoduric bacteria are important with regard to milk and milk products as they may survive pastourisation temperature the genera Micrococcus, Streptococcus primary the entrococci, Lactobacillus, Bacillus and Clostridium are recognized as containing some species which will qualify as thermoduric. The thermoduric count may be useful as a test of the care employed in utensil sanitation and as means of detecting sources of organisms responsible for high bacterial count in pasteurized. Lipolytic Microorganisms Are those organisms capable of hydrolytic and oxidative deterioration of fats, mostly cream, butter, marganine, etc the genera Pseudomans, Achromobacter, and staphylococcus among other bacteria, Rhizopus, Geotrichum, Aspergillus and penicillium among the moulds and the yeast genera Candida, Rhodotorula, and Hansenula contain may lipolytic species. Proteolytic microorganisms Proteolytic microorganisms are those microorganisms capable of hydrolyzing proteins producing a variety of odour and flavour defects Proteolytic species are common among the genera Bacillus, Clostridim, Pseudomoans, and proteus. Acid proteolytic organisms are those organisms which carry out protein hydrolysis and acid fermentation as streptococcus faecalis var. Most of the slight halophilic bacteria originate from marine environments Marine psychrophilic bacteria of the genera pseudomonas, Moraxella. Acinetobacter, and Flavobacterium contribute to the spoilage of marine fish and shelfish Moderate halophiles grow optimally in media containing 5. They have been incriminated in spoilage of fish, and hides preserved in sea salts. Halotolerant organisms Are those organisms capable of growth in salt concentrations exceeding 5%. Some halotolerant microorganisms are involved in food spoilage while some others such as staphylococcus aureus and cl. Almost all of the the known osmophillic yeasts are species of saccharomyces species. Pectinolytic microorganism Are those microorganisms capable of degrading pectins foun in fruites and vegetables. The pectinolytic organisms includes species of Achrobacterium, Aeromonas,Arthrobacter, Bacillus, Enterobacer etc. It also includes many yeasts and moulds Acid producing microorganisms An important group of acid producing bacteria in the food industry is the lactic acid bacteria this group is subdivided into the genera streptococcus, Leuconostoc, Pediococcus and Lactobacillus. Many sporeforming species belonging to the genera Bacillus and Clostridium are also important acid producers 353 Some mould and yeasts produce citric acid, oxalic acid,etc. Yeasts and moulds Yeasts and moulds can be responsible for spoilage of many types of foods They often manifests themselves in foods of low pH, low moisture, high salt or sugare content, etc. They are resistant to heat freezing, antibiotics Mesophillic spore forming aerobes the mesophilic, aerobic spore forming bacteria are all strains Bacillus species that grow at 350c but not at 550c. Inadequate heat processing is commonly responsible since spores of mesophillic bacteria are moderately resistant to moist heat. Thermophillic anaerobes these organisms are obligatory anaerobes and are strongly saccharolytic, producing and abundant gas from different sugars they non hydrogen sulphid producers They are responsible spoilage of canned food products. Microbiological Examination of Food Sampling It is important to not that samples of foods collected for microbiological analysis should reflect the microbiological condition at the time of collection. This implies that 354 · Sampling should be carried out aseptically Samples should be protected against extraneous contamination Moreover, samples must be held under conditions that permit neither die off nor multiplication of the original microflora present in the food. Definintion of terms A lot · Is a quantity of food produced and handled under uniform condition. This means that food produced within a batch or in a continuous process a food produced within a limited period of time · the number of field samples collected are usually five. But for the investigation of food for salmonella the number of field sample is ten Filed sample: the amount of material actually used in the analysis of food for microorganisms. The sample unit is recommended to be 25 g for all types of food Microbiological criteria A microbiological criteria is a microbiological value (eg. Number of microorganism per g of food) or a range established by use of defined procedures and includes the following information. A statement of the microorganism of concern and/or the toxin 355 the analytical methods of their detection and quantification A plan refining the number of field sample to be withdrawn and the size of the sample unit the microbiological limits considered appropriate to the food the proportion of the sample units that should conform to these limits. It gets its bacterial contamination after oviposition from nesting material, dirt, and faecal matter.

Implementing a better bundle to achieve and sustain a zero central line-associated bloodstream infection rate. Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multi-modal intervention focusing on line maintenance. The following summarizes information from the 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70-percent alcohol can be used as alternatives. Weigh the risk and benefits of placing a device in subclavian site to reduce infectious complications against the risk for mechanical complications compared with jugular site. Medications compounded outside of the laminar airflow workbench are deemed to be critical in need and must be used within one hour of the preparation time. Cleaning is not limited to multidose vials; it applies to all vials (even single dose vials). The plastic cap covering the top of all vials is not intended to provide a sterile injection surface. The sample size, exclusions, methodology, and potential bias are important considerations. Use clinical judgment regarding the appropriateness of removing the catheter if infection is advanced elsewhere or if an infectious cause of fever is suspected. Verify compliance with institutional policy regarding time frames for use and replacement. Verify compliance with institutional policy regarding time frames for (a) duration of use and (b) replacement. Determine compliance with institutional policy regarding connector replacement frequency. Identify if institutional policy describes special circumstances for connector replacement. Analyze the type of connector/valve used by the institution; in some cases, the institution may use more than one type. Understand the infectious risk potential associated with the external and internal design features of connectors currently in use. Routine replacement of needles used to access implanted ports; length to time the needle may remain in place Replacement of needleless connectors Unresolved issues Unrated Not addressed Change the needleless connector at least as frequently as the administration set. Change no more frequently than every 72 hours or according to manufacturer recommendations for the purpose of reducing infection rates. A split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves. Determine whether this type pf securement product is available at the time of insertion/included in kits or carts. Determine which types of antimicrobial catheters are used by the institution and the circumstances under which they are inserted. Determine whether antimicrobial connectors are used, and, if so, review supporting studies, design specifications, and outcomes in areas where these devices are used. Determine whether disinfecting caps are used and, if so, whether or not they are intended to remain in place on the connector. Investigate to ensure that that disinfecting caps are used consistently and per manufacturer instructions. Facility-specific studies support the use of readily accessible, standard supplies to support optimum infection risk reduction. The guidelines identify these recommendations as the following:1 · Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infection. Category I When attempting to implement evidence-based practices into daily work, it has been stated that there is too much reliance on education and transmission of information as a change strategy; furthermore, lack of time and staff autonomy contribute to the challenges of implementation. Highlights of the framework include:2 · Engage: Involving frontline and senior leadership in the process and outcome improvement plan; focusing on a safety culture and involving local champions. The insertion of a central line poses numerous risks for the patient, especially if the physician is new to practice and/or does not perform this skill regularly. These procedurally structured programs increase skill mastery, enhance confidence, and reduce the risk of complications at the time of insertion. Although simulation training for central catheter insertion has not been extensively studied, the initial results are promising. Initially studies focused on the reduction of common complications, such as the need for multiple needle passes; pneumothorax; and arterial puncture.

Over the years, the use and abuse of clandestinely produced amphetamines have spread. Today, clandestine laboratory production of amphetamines has mushroomed, and the abuse of the drug has increased dramatically. Common street names include: · Bennies, Black Beauties, Crank, Ice, Speed, and Uppers What is their effect on the body? Physical effects of amphetamine use include: · Increased blood pressure and pulse rates, insomnia, loss of appetite, and physical exhaustion What are their overdose effects? Overdose effects include: · Agitation, increased body temperature, hallucinations, convulsions, and possible death Which drugs cause similar effects? Drugs that cause similar effects include: · Dexmethylphendiate, phentermine, benzphetamine, phendimetrazine, cocaine, crack, methamphetamine, and khat What do they look like? Pharmaceutical products are available only through a prescription that cannot be refilled. However, the addition of "ice," the slang name of crystallized methamphetamine hydrochloride, has promoted smoking as another mode of administration. The effects of amphetamines and methamphetamine are similar to cocaine, but their onset is slower and their duration is longer. Cocaine is an intense, euphoria-producing stimulant drug with strong addictive potential. The cocaine manufacturing process takes place in remote jungle labs where the raw product undergoes a series of chemical transformations. Colombia produces about 90 percent of the cocaine powder reaching the United States. Common street names include: · Coca, Coke, Crack, Flake, Snow, and Soda Cot Cocaine powder What does it look like? Cocaine is often diluted ("cut") with a variety of substances, the most common of which are sugars and local anesthetics. It is "cut" to stretch the amount of the product and increase profits for dealers. In contrast, cocaine base (crack) looks like small, irregularly shaped chunks (or "rocks") of a whitish solid. Following smoking or intravenous injection, cocaine reaches the brain in seconds, with a rapid buildup in levels. Other effects include increased alertness and excitation, as well as restlessness, irritability, and anxiety. Taking high doses of cocaine or prolonged use, such as binging, usually causes paranoia. The crash that follows euphoria is characterized by mental and physical exhaustion, sleep, and depression lasting several days. Powdered cocaine can be snorted or injected into the veins after dissolving in water. Cocaine is also used in combination with an opiate, like heroin, a practice known as "speedballing. Cocaine users typically binge on the drug until they are exhausted or run out of cocaine. Physiological effects of cocaine include increased blood pressure and heart rate, dilated pupils, insomnia, and loss of appetite. The widespread abuse of highly pure street cocaine has led to many severe adverse health consequences such as: · Cardiac arrhythmias, ischemic heart conditions, sudden cardiac arrest, convulsions, strokes, and death In some users, the long-term use of inhaled cocaine has led to a unique respiratory syndrome, and chronic snorting of cocaine has led to the erosion of the upper nasal cavity. Other stimulants, such as methamphetamine, cause effects similar to cocaine that vary mainly in degree. Cocaine hydrochloride solution (4 percent and 10 percent) is used primarily as a topical local anesthetic for the upper respiratory tract. It also is used to reduce bleeding of the mucous membranes in the mouth, throat, and nasal cavities. However, better products have been developed for these purposes, and cocaine is rarely used medically in the United States.

Clinicians need to be constantly aware that a patient may be abusing multiple substances. Even if a patient admits the abuse of one sub stance he may not admit to using others. Patients may not see that other substances are a problem, they may be worried about the legal consequences of use, or they sometimes may not even be aware of what substances they have been using. Interviews with family, friends, or oth ers who know the patient may be helpful, but these also are insufficient. The consensus panel strongly recommends that all patients receive an immediate urine drug screening upon admission to a detoxification program to determine the types of substances being abused. It is not necessarily true that the per son is drug free simply because a drug is not detected on a drug screen. It is possible that the toxicology is not able to detect the class or type of drug. Staff should be aware of what the program/detoxification center/hospital tests for, what is not tested for, what cannot be tested for or found, and the limitations of "dip" tests. Therefore, it is generally best practice to prioritize the substances an individual has been dependent on and treat them sequentially according to the severity of the withdrawal pro duced by the substance. The substances with the most serious withdrawal syndromes, those where the withdrawal syndrome can be fatal, are alcohol and the sedativehypnotics. When detoxifying a patient who has been dependent upon multiple substances, the sedativehyp notics must be addressed first. After the patient has been tapered off of the sedative hypnotic or anxiolytic, withdrawal from the substitute opioid can begin (Wilkins et al. Some patients can successfully be detoxified from both sedativehypnotics and opioids simultaneously, but this requires a great deal of medical and nursing attention. Most patients will benefit from opioid mainte Chapter 4 nance for an extended period of time follow ing the completion of sedative withdrawal. If the patient has been abusing multiple seda tivehypnotic substances or a sedativehypnotic and alcohol, withdrawal should be handled in the same way as withdrawal from one such sub stance. The patient should be administered a regularly decreasing dosage of sedativehypnot ic, usually a benzodiazepine that the clinician is comfortable with and accustomed to using. Phenobarbital also may be used for detoxifying patients who have been abusing both alcohol and benzodiazepines. When the dose of alcohol and sedativehypnotics that a patient is taking is not known, tolerance testing as previously described can be helpful in determining the dose of phenobarbital. When treating patients detoxifying from sub stances other than sedativehypnotics, manage ment of opioid detoxification should be the next priority. Patients may abuse a wide range of substances in various combinations, and the clinician must be vigilant in assessing and treating withdrawal from multiple substances. The case study above illustrates some of the serious problems the clinician faces in evaluating and treating patients withdrawing from multiple substances. In the private sector, where money for toxico logical screening is readily available, the first question many would ask concerning the case of Mr. Toxicological screening, even a handheld screening, can be an expensive item for what often is a very limit ed budget. Besides, in this case, the patient was believed to be a known quantity-someone who only used heroin. One of the more frightening facts con cerning the purchase of illicit drugs is the lack of knowledge of what is in them. To make buy ers believe that they are buying a higherquali ty product than they are, drugs often are cut with adulterants (inferior ingredients) that can produce effects similar to the drug they think they are buying. L may have been buying barbiturates and benzodiazepines in his heroin for some time without knowing it, a fact that could have had deadly conse quences. Both are sedating and could have given him some of the comfortable sedation and euphoria he was seeking from his drug of choice. Unfortunately, however, where opioid withdrawal is not lifethreatening, withdrawal from barbiturates can be. Alternative Approaches Alternative methods that have been studied sci entifically do not claim to be standalone with drawal methods, nor standalone treatment modalities. Alternative approaches are designed to be used in a comprehensive, inte grated substance abuse treatment system that promotes health and wellbeing, provides pal liative symptom relief, and improves treatment retention. Therefore, because isolation of any of these approaches as an independent variable in rigorous controlled studies is difficult, if not impossible, there are no conclusive data on the effectiveness of alternative methods (Trachtenberg 2000).