Infection Prevention and Control Guideline for Cystic Fibrosis 2. Update on JSTORUpdated Recommendations for IP C in CFI. Core Recommendations. The CF Foundation recommends implementation of the following core IP C recommendations to minimize the risk of transmission and acquisition of pathogens among all people with CF, including following lung or liver transplantation, in all settings. EducationAdherence Monitoring for Healthcare Personnel, People with CF, and Families. The CF Foundation recommends that all healthcare personnel caring for people with CF eg, the CF care team, inpatient staff, environmental services staff, research staff, and staff in diagnostic and therapeutic areas, including pulmonary function test PFT laboratories, radiology, phlebotomy, operating room, and physical therapy receive education regarding IP C for CF, using principles of adult learning. RR8qD/526x297-StW.jpg]];var lpix_1=pix_1.length;var p1_0= [[250' alt='Download Blood Cell Morphology Grading Guide Pdf' title='Download Blood Cell Morphology Grading Guide Pdf' />Vol. No. 3, May, 2004. Mathematical and Natural Sciences. Study on Bilinear Scheme and Application to Threedimensional Convective Equation Itaru Hataue and Yosuke. Patients With Chronic Obstructive Pulmonary DiseaseRespiratory Insufficiency Recommendations. Patients With. Education should be repeated at intervals each center deems appropriate. Source of supporting evidence 2. CF IP C guideline, Category II 2. MDRO guideline, Category IB 2. Category IB2. 01. CF IP C guideline consensus 1. Sections in the text III. Margareta-Blomback-Essential-Guide-to-Blood-Coagulation1405196270.jpg' alt='Download Blood Cell Morphology Grading Guide Pdf' title='Download Blood Cell Morphology Grading Guide Pdf' />Morphine Sulfate is the sulfate salt of morphine, an opiate alkaloid isolated from the plant Papaver somniferum and produced synthetically. Morphine binds to and. Sacroiliitis Associated with Axial Spondyloarthropathy New Concepts and Latest Trends. Infection Prevention and Control Guideline for Cystic Fibrosis 2013 Update. D. 2 IV. B2. The CF Foundation recommends that the CF care team develop strategies to monitor adherence to IP C practices by healthcare personnel and provide feedback. Feedback to the CF care team includes immediate feedback to an individual when a lapse in practice is observed and feedback to the entire CF care team of trends of overall adherence rates at regular intervals eg, quarterly on the basis of consistency of practices. Source of supporting evidence 2. CF IP C guideline, Category IB 2. MDRO guideline, Category IB 2. Category IB2. 01. CF IP C guideline consensus 1. Sections in the text IV. B IV. E. 1. 3. The CF Foundation recommends that all people with CF and their families receive education regarding IP C for CF, using age appropriate tools and readinglanguage level appropriate to the target audience. Involve people with CF and their families in the development of educational programs and implementation of recommended practices. Education should be repeated at intervals each center deems appropriate. Source of supporting evidence 2. CF IP C guideline, Category II2. CF IP C guideline consensus 1. Sections in the text IV. BPartnering with Institutional IP C Teams. The CF Foundation recommends that CF care teams collaborate with their institutional IP C teams to implement the recommendations in this guideline. Source of supporting evidence 2. MDRO guideline, Category IB2. CF IP C guideline consensus 1. Sections in the text I. D IV. B IV. E. 1, 2 IV. F5. The CF Foundation recommends that CF care teams collaborate with their institutional IP C teams to develop protocols, checklists, and audits to standardize implementation of practices for the following a. Single patient use, disposable itemsb. Cleaning and disinfecting multiuse items eg, patient care equipment, oximeters, i. Pads and similar tablets, and computersc. Cleaning and disinfecting surfaces in the healthcare environment eg, CF clinics, PFT rooms, hospital rooms, and sinks and showers6. The CF Foundation recommends ensuring that dust containment during renovation and construction and water leak remediation policies and practices are followed according to institutional and national guidelines in all ambulatory care areas and inpatient settings where people with CF receive care. Source of supporting evidence 2. CF IP C guideline, Category IBIC 2. CDC environmental guideline, Category IBIC2. IP C guideline consensus 1. Sections in the text III. D. 3 IV. H7. The CF Foundation recommends that healthcare personnel assume that all people with CF could have pathogens in respiratory tract secretions that are transmissible to other people with CF. Source of supporting evidence 2. CF IP C guideline, Category IA2. CF IP C guideline consensus 1. Sections in the text IV. F. 1 IV. GPractices for Healthcare Personnel. The CF Foundation recommends that all healthcare facilities caring for people with CF ensure ready availability of alcohol based hand rub or antimicrobial soap and water in all patient rooms, PFT rooms, and waiting areas. Source of supporting evidence 2. CF IP C guideline, Category IA 2. WHO and 2. 00. 2 hand hygiene guidelines, Category IA2. CF IP C guideline consensus 1. Sections in the text IV. B IV. F. 3. 9. The CF Foundation recommends that healthcare personnel perform hand hygiene either using alcohol based hand rub or washing hands with antimicrobial soap and water, as per CDC and WHO guidelines, in the following clinical situations a. Before entering the room and when leaving the room of any patientb. Before and after direct contact with any patientc. Before putting gloves on and after removing gloves, for both sterile and nonsterile proceduresd. After contact with patients skin, mucous membranes, respiratory secretions, or other body fluidse. After contact with inanimate objects including medical equipment in the vicinity of the patient that may be potentially contaminated with respiratory secretions. Source of supporting evidence 2. CF IP C guideline, Category IA 2. WHO and 2. 00. 2 hand hygiene guidelines, Category IASections in the text IV. C IV. F. 3. 10. The CF Foundation recommends that healthcare personnel should not wear artificial fingernails or nail extenders when having direct contact with people with CF. Source of supporting evidence 2. HICPAC hand hygiene, Category IA for high risk patients 2. WHO hand hygiene, Category IA for all patients. Sections in the text IV. C1. 1. The CF Foundation recommends that healthcare personnel should disinfect their stethoscopes before and after use on each patient in accordance with institutional IP C policies. Stethoscopes that remain in the patients room and are dedicated for use only for that patient do not need to be disinfected before and after use. Source of supporting evidence 2. MDRO guideline, Category IB2. CF IP C guideline consensus 1. Sections in the text III. D. 2 IV. E. 2 IV. F. 7 IV. G1. 2. The CF Foundation recommends that healthcare personnel caring for people with CF should not be routinely screened for MRSA colonization unless they are epidemiologically linked to a cluster of MRSA infections in accordance with institutional IP C policies and national guidelines. Source of supporting evidence 2. MDRO guideline, Category IBSections in the text III. B. 2. Isolation Precautions. The CF Foundation recommends that all healthcare personnel implement Contact Precautions ie, wear a gown and gloves when caring for all people with CF regardless of respiratory tract culture results, in ambulatory and inpatient settings. Source of supporting evidence 2. Category IBIC2. 01. CF IP C guideline consensus 1. Sections in the text II. A IV. D. 1 IV. G1. The CF Foundation does not recommend that healthcare personnel wear a mask routinely when caring for people with CF. However, the CF Foundation recommends mask use per CDC guidelines, as follows a. Surgical procedure, isolation masks are worn by healthcare personnel caring for any patient under Droplet Precautions with suspected or confirmed pathogens that are transmitted by the droplet route eg, adenovirus, rhinovirus, influenza virus, or Mycoplasma pneumoniae. Guidelines for the investigation and management of mantle cell lymphoma Mc. Kay 2. 01. 2 British Journal of Haematology. There is a lack of definitive data to guide treatment of MCL, partly because it is a relatively uncommon condition and partly because it was only recognized as a specific entity in the revised European American classification of lymphoid neoplasms REAL classification published in 1. Harris et al, 1. 99. In addition, MCL patients have frequently been included with other NHL types in clinical studies. Therefore, it is recommended that, where possible, patients with MCL should be managed within the context of a clinical trial. Details of how to obtain information regarding UK clinical trials for patients with MCL can be found in Appendix Appendix. The guidance below suggests options and recommendations for patients not treated in a clinical trial. Where possible, discussion is restricted to published studies including more than 1. MCL patients. Four very large studies currently published in abstract form are considered of major significance in the field Le Gouill et al, 2. Kluin Nelemans et al, 2. Hermine et al, 2. Rule et al, 2. 01. Early stage MCLA very small proportion of patients will present with localized MCL. As such, evidence for management of this group is scarce. However, in this situation, involved field radiotherapy may be appropriate and can result in long term remissions. MCL is radiosensitive, and radiotherapy has been used as single agent therapy for localized disease with good responses Rosenbluth Yahalom, 2. Another retrospective study reported outcomes in 2. IA and IIA MCL Leitch et al, 2. Radiotherapy was administered to 1. Dino Crisis 1 Full Version. In spite of small numbers, the study did demonstrate an advantage of radiotherapy in this group 5 year progression free survival PFS of 6. RT. In addition, a retrospective analysis from the British National Lymphoma Investigation Group BNLI Vandenberghe et al, 1. Fifteen patients had stage I or II disease, and were treated with local radiotherapy. Twelve 8. 0 of these patients attained a complete response CR. Responses were sustained eight of the 1. CRs at 1. 56, 1. 90 and 1. MCL may be curable with radiotherapy in a small proportion of cases. If early stage disease is suspected, staging should be confirmed with bone marrow examination and GI investigations as described above. Outside the context of a clinical trial, radiotherapy, with or without chemotherapy, would be a reasonable approach. Advanced stage MCLMCL is now recognized as having the worst outlook of all subtypes of lymphoma. Although many patients respond well to initial chemotherapy, remission duration is short and overall survival OS is poor. As has been discussed in the introduction, a small subgroup of patients has disease that behaves in a more indolent fashion. If they are asymptomatic, it is reasonable to adopt a watch and wait policy. A retrospective study of 9. Martin et al, 2. 00. It is of note, however, that patients in this study were monitored closely, and generally started treatment after months rather than years. The majority of patients will, however, require chemotherapy. Once the decision is made to treat the patient, the choice of regimen will depend on the overall aim of therapy. Clinical trials of first line treatment in MCL are summarized in Table 5. An early distinction should be made between younger patients fit to undergo autologous peripheral blood stem cell transplantation ASCT, and those less fit patients for whom this is not an option. For younger, fitter patients where the aim is to proceed to high dose HD therapy and autograft in first remission, chemotherapy should be given with the aim of obtaining as good a remission as possible. Table 5.  Clinical trials of combination chemotherapies in MCL in patients treated first line. Conventional. FCCohen et al 2. FCLefrere et al 2. CHOPLenz et al 2. NRCOPMeusers et al 1. CHOPMeusers et al 1. FCRule et al 2. 01. CVPTeodorovic et al 1. COPUnterhalt et al 1. Fludarabine. Zinzani et al 2. Fludarabineidarubicin. Zinzani et al 2. MCPHerold et al 2. Combined immunochemotherapy. R chlorambucil. Bauwens et al 2. R CHOPHoward et al 2. R CHOPLenz et al 2. Not reached. R FCRule et al 2. R cladribine. Spurgeon et al 2. R MCPHerold et al 2. Dose intense regimens. Maxi CHOP cytarabine, ASCTGeisler et al 2. CR6 year PFS 5. 64 year OS 7. R Hyper CVADhigh dose MTX cytarabine. Romaguera et al 2. Not reached at 1. Hyper CVADhigh dose MTX cytarabine. Khouri et al 1. 99. R hyper CVADRitchie et al 2. CR9. 2 at 3. 6 months. However, the majority of patients are elderly, where a high dose therapy approach is not feasible. For these patients, a range of chemotherapy options is available, in combination with rituximab, and these are discussed below. It is acknowledged however, that for this group, there is no gold standard therapy, and it is difficult to recommend any specific regimen. Conventional chemotherapy for patients not fit for high dose regimens. Historically, MCL was grouped with low grade lymphomas in clinical studies and treated with regimens including CVP cyclophosphamide, vincristine, prednisone Meusers et al, 1. Teodorovic et al, 1. Unterhalt et al, 1. Cohen et al, 2. 00. CHOP cyclophosphamide, vincristine, doxorubicin, and prednisone Meusers et al, 1. Lenz et al, 2. 00. Nickenig et al, 2. Most of the studies had small numbers but the general pattern was of reasonable overall response rates ORR, 6. PFS 72. 1 months and poor OS of 4. No particular combination appears superior in terms of OS. In particular, addition of an anthracycline in the only randomized controlled trial RCT performed Meusers et al, 1. This has been confirmed in large retrospective analyses. The Nebraska Lymphoma Study Group demonstrated that, although 7. Weisenburger et al, 2. Similarly, the Barcelona experience showed an ORR of 6. Bosch et al, 1. 99. In those not fit for the more intensive induction regimens discussed below, there is no evidence that adding anthracycline confers any advantage. However, despite the lack of robust evidence, R CHOP CHOP  rituximab remains a widely used combination chemotherapy regimen in this disease and forms the control arm in many randomized studies. For this reason, we have included it as a treatment option. The effectiveness of purine analogues in MCL has been studied in the front line setting, with mixed results. When used as a single agent, ORRs of around 3. Ghielmini et al, 2. Grillo Lopez, 2. However, when used in combination with cytotoxic agents, such as idarubicin or cyclophosphamide, ORRs increase to approximately 6. Zinzani et al, 1. Cohen et al, 2. 00. The haematological toxicity of the purine analogues must not be forgotten however, and, in addition to the recognized infectious morbidity, they may cause difficulty with stem cell mobilization when this is undertaken Dreyling Hiddemann, 2. Eve et al, 2. 00. A large study of the European MCL Network randomized 5. R CHOP 8 and R FC rituximab, fludarabine, cyclophosphamide 6 Kluin Nelemans et al, 2. Response rates were poorer in the R FC arm and, of note, OS was lower in the R FC arm 4. P  00. 07. 2, with particularly high infection rates, reinforcing the notion that the haematological toxicities of purine analogues mean that caution should be exercised when administering these agents to elderly MCL patients.