Florence Nightingale antibiotic drops for eyes discount cefadroxil 250mg with mastercard, the prime example of a nursing leader virus on mac computers quality cefadroxil 250mg, had a vision of what nursing should be antibiotic journal pdf purchase 250 mg cefadroxil overnight delivery, and her vision still guides nursing to this day antimicrobial bath towels cefadroxil 250mg line. Leadership Theories Over many years antibiotic stewardship purchase cefadroxil 250mg line, study and research have led to theories of leadership antimicrobial workout clothes purchase cefadroxil 250 mg online. These theories form the basis of thought about how a leader accomplishes work through the efforts of other people antibiotics joint replacement dental work order cefadroxil 250 mg free shipping. The most commonly held theories include trait antibiotics for urinary tract infection uk buy generic cefadroxil 250mg on-line, contingency, path-goal, human relations, and transformational. Leaders in government, the military, and industry were studied, and their traits were identified. Trait theory proposes that leaders are born with such traits as intelligence, initiative, drive, aggressiveness, and ambition and that these traits are related to being a successful leader. Contingency Theory the contingency theory of leadership looks at not only the leader but also the followers and the organizational perspectives (goals and objectives). Path-Goal Theory the path-goal theory describes an effective leader as one who assists the follower along the path toward a goal. This leader leads by coaching, providing guidance, and giving incentives that may not be customarily available. Human Relations Theory Human relations theory focuses both on the leader and the followers with whom the leader interacts. Transformational Theory Transformational theory applies to the leader who is able to bring out the best in others. Interactions between this leader and others are mutually uplifting and encouraging. This leader has charisma, provides idealized influence, intellectual stimulation, and inspiration and considers followers individually. Most often, a leader exhibits some characteristics of each style of leadership, though one style will typically be more dominant. It is important to understand the various styles of leadership so you can identify and understand the approach of leaders and determine how to work most effectively with them. Also, it is important for you to have an understanding of your own predominant style of leadership. Knowing your style allows you to reinforce or alter it to enhance its effectiveness. Self-awareness about your predominant leadership style is the first step to being an effective leader. Five styles of leadership are autocratic, democratic, laissez-faire, participative, and situational. Autocratic Autocratic leadership is task oriented and is based on the premise that the leader knows best. This leader is often viewed as controlling and inhibiting of the creativity and autonomy of workers. The leader solves problems and makes decisions without consulting the parties involved. The leader exercises responsibility for ensuring the work is done by issuing commands or orders to direct the work force and motivates others through praise, blame, and reward. When workers have a certain degree of knowledge and teamwork is important, this style of leadership is not effective. When working with an autocratic leader: Both praise and criticism are given. Although democratic leadership is time consuming, the benefit is seen in increased cooperation and teamwork. This leader focuses on the individual characteristics and abilities of the workers and keeps in mind the commitment to whatever is best for the group. Individual workers are encouraged to participate in decision making and to express their viewpoints. This approach may not be effective when there is conflict within the group or when time is short. Problems occur when there is an emergency and there is no time for the group to process the information and come to a decision. When working with the democratic leader: Each person is viewed as a unique individual. The dissatisfaction level, which often is high, is caused by the lack of guidance, caring, and instructions. The group is often out of synchrony with the rest of the organization because information is not passed on to them. Task achievement is difficult under this leadership form, so it is not a style of leadership used frequently in health care. The participative leader makes proposals to the group, invites group criticism and comments, and then uses the feedback to make the final decision. Employees may freely share their ideas and contribute to the goal-setting process. This leader is confident in his or her own abilities and allows control and power to spread throughout the group. When working with a participative leader: the work group has an active role in decision making. Any or all of the previously described leadership styles may be needed in a particular situation. The effective leader identifies which style to use in the specific circumstance and which style to use with the individual persons involved. Leadership Skills Many theories of leadership cite several skills needed for effective leadership. These skills include communication, assertiveness, critical thinking, self-evaluation, and time management. In addition, leaders must be able to convey ideas and information clearly, concisely, and persuasively to effectively implement changes in the delivery of nursing care. By being assertive, a person claims responsibility for his or her own feelings, thoughts, and actions. Using I in statements shows that the person accepts responsibility for feeling, thinking, and doing. Hill and Howlett (2001) suggest three rules for being assertive: Own your feelings. Critical Thinking Critical thinking skills incorporate the ability to analyze all aspects of a problem, explore options, find solutions, and implement changes. Leaders seek information, consult experts, and use available resources to address problematic situations and to enhance care. Self-Evaluation the self-evaluation skills necessary for effective leadership involve an honest assessment of personal strengths and weaknesses. After such an assessment, efforts are made to enhance personal growth and development. Time Management Time management is a technique to help individuals get things done efficiently and effectively. They set priorities for tasks to be completed and then see that the tasks are done the best way possible. Management is the accomplishment of tasks through the effective use of people and resources. Management involves the practical "nuts and bolts" of getting the job done with the available resources. Nurses are in positions that require them to manage people and resources used to deliver quality client care. Managing the needs of a group of clients or managing the activities of a group of nursing assistants requires the same skills. Practice and education can help develop the management skills and, potentially, the leadership skills of every nurse. The ability of a specific staff member to perform a specific task is based on level of education and experience. Overlap exists, however, and determining who can legally do what is often confusing. Within the scope of practice, there are tasks and responsibilities the individual may or may not be competent to implement. The scope of competence expands as new skills are acquired, but all skills must fall within the scope of practice. Licensed practical/vocational nurses are qualified to care for clients with common illnesses and to provide basic and preventive nursing procedures. Licensed practical/vocational nurses can participate in data collection, planning, implementation, and evaluation of nursing care in all settings. Being available by an answering machine or service does not fall within the definition of "immediately available. Nancy works in a long-term care facility as the evening-shift charge nurse on 4 West. She also monitors their work and intervenes when necessary to ensure that clients receive safe and appropriate care. Leadership roles and management functions in nursing theory and application (3rd ed. Through formal education and clinical supervision, you have studied and learned the skills necessary to become competent in providing client care. Therefore, do not be discouraged if you are unable to obtain employment as a graduate nurse during this period. All questions on the examination are classified by test plan area and level of difficulty. If this is answered correctly, the next question the computer selects is more difficult. As long as the questions are answered correctly, the next question the computer selects is more difficult. When a question is answered incorrectly, the next question the computer selects is less difficult. Questions continue getting easier until a question is answered correctly, then the questions again become a little more difficult. This zigzag pattern continues until the candidate answers about 50% of the questions correctly (Figure 2-2). The computer selection of questions gives each candidate the best opportunity to demonstrate competence. Because everyone answers about 50% of the questions correctly, the difficulty of the questions answered correctly makes the difference in determining whether that candidate passes or fails. Each candidate has a unique test (different questions and a different number of questions) based upon the answers given to the questions. Licensure endorsement from one board of nursing to another is facilitated because all boards of nursing use the same examination. Results are mailed to the candidate by the state board of nursing 1 month or less after the examination. Candidates may retake the examination; however, the National Council requires a wait of at least 91 days between testings. These concepts and processes are nursing process, caring, communication, cultural awareness, documentation, self-care, and teaching/learning. However, some of the subcategories are different, and the content included under each subcategory is different. Candidates answer a minimum of 85 questions and a maximum of 205 questions during the maximum 5-hour testing period (National Council of State Boards of Nursing, 2003). Registered nurse candidates answer a minimum of 75 questions and a maximum of 265 questions during the maximum 5-hour testing period (National Council of State Boards of Nursing, 2001). Several are listed in the References/Suggested Readings at the end of this chapter. The major part of the review book is made up of multiple choice questions covering all areas of the test plan. Be sure to read each question and all four answers carefully before choosing an answer. By eliminating one or two of the answers, you will have a better chance of choosing the correct answer. Plan the number of questions to answer during each study time so that all will be completed a day or two before you are scheduled to take the exam. Choose the method for review that best fits into your schedule and way of studying. As a graduate, it is your task to determine the setting that constitutes the best fit for you. The area of growth for employment in the hospital will be in outpatient facilities such as same-day surgery, rehabilitation, and chemotherapy (Bureau of Labor Statistics, 2000b). Nurses in this setting will also provide care to clients who have been released by the hospital but who are not yet well enough to go home and who need additional rehabilitative services (Figure 2-3). Community Health Agencies In the community health setting, care is provided to clients through established health care programs. Private Duty Private duty nurses are self-employed, meaning the nurse is hired and paid directly by the client. Nurses work under the direction of a physician but must rely on their own knowledge and judgment to provide care. Private duty nurses are responsible for handling all matters of licensing and finances on their own. Home Care Agencies In the home care setting, care is provided to clients in their own homes. The nurse is generally employed by an agency but will work in the home of an assigned client. A much faster than average growth is expected in this area of nursing owing to both a consumer demand for home care and the lower costs of caring for an individual in the home (Figure 2-4). Hospice Hospice nursing care consists of providing comfort to dying clients and their families. The role of the nurse is to alleviate pain and other symptoms but not to provide curative care. The clients in the hospice setting are terminally ill and typically have fewer than 6 months to live. Hospice services are most often rendered in the home, but services can also be offered in other settings. Occupational Health Occupational health nursing serves to provide safe working environments in industrial workplaces. Correctional Facilities Correctional nursing is the branch of nursing that provides care within prisons, youth detention centers, and probation divisions. Care provided ranges from ambulatory care to emergent care to comprehensive health care. Parishes Parish nurses provide health care education and support to a congregation. The care is designed to meet the common needs and beliefs of a specified group of people (Palmer, 2001). This is not necessarily a bad place to identify potential employers; after all, an organization that is advertising is probably hiring. The problem with relying solely on this approach is that it limits you to the jobs that are available rather than the job you want. Remember, using this method, you are in competition with all the other job seekers who are relying on want ads to identify employment options. The telephone directory is a great place to identify health care facilities in your area. You are likely to find far more health care facilities in your local area than you ever imagined. Job counselors disagree on the usefulness of telephoning the employers to determine whether job vacancies exist: Some claim that a telephone call is a quick method of determining vacancies, whereas others believe a face-to-face visit to the facility yields better results. Your colleagues in the club may also offer insights into those areas of nursing for which they believe you are most suited. Most important, go after any job that looks interesting to you regardless of whether there is a known vacancy. However, right around the corner from your home may be the less wellknown school for developmentally disadvantaged children, and waiting there may be your ideal job! Professional job placement services are also available, but they usually charge a fee. Corporate Web sites often post job openings along with job-seeking information and tips (Smith, 2000). The job search requires up-front preparation on your part to organize and pinpoint the areas where you would like to concentrate your efforts. If you cannot envision yourself as a medication nurse in a long-term care facility, there is very little reason to apply for such employment in that setting. First, once you know your objective, you will know where to focus your efforts in identifying potential employers. You will be prepared to tell prospective employers precisely the ways that you can be of benefit to them. If you are having difficulty pinpointing your objective, think back to other jobs or volunteer projects in which you have been involved. List your strongest four to six skills: these are the skills that you want to use in your new job and that will be valuable in identifying your objective. The skills needed for a particular job can be identified in a number of ways, including the following: Talking to people in nursing positions and asking them what they like and do not like about their jobs. During clinical in nursing school, you may have already talked to nurses and have more information than you realize. Once you have matched your skills to the skills required in a particular job, you have effectively identified your job objective. The focus should be on verifiable skills or accomplishments that suggest what you can do for an employer who hires you.
Citrus Bioflavonoid (Hesperidin). Cefadroxil.
Internal hemorrhoids, when used in combination with diosmin.
Xanthan gum is more effective in preventing syneresis of freeze-thawed sweet potato starch gel at 0 bacteria chapter 7 cheap cefadroxil 250 mg mastercard. Dextran-producing Leuconostoc species and Weissella are widely used for this purpose (Pepe et al bacteria good and bad purchase cefadroxil 250 mg without prescription. Enhanced immunostimulatory activity was exhibited by high molecular weight glucans with (1 antibiotics before surgery discount 250 mg cefadroxil mastercard,6) linkages antibiotics for acne while pregnant cheap 250 mg cefadroxil fast delivery. It is used to make resins in separation technology and also as microcarrier in tissue/cell cultures antibiotics for diverticulitis purchase cefadroxil 250 mg with visa. It is used as a viscosifier xtenda antibiotic purchase 250 mg cefadroxil free shipping, stabilizer antibiotic resistance uk statistics discount 250 mg cefadroxil otc, emulsifier infection nursing diagnosis cefadroxil 250mg on-line, and suspending agent in the food industry. In addition, it used in paints, pesticide and detergent formulations, pharmaceuticals, cosmetics, printing inks, and secondary and tertiary crude-oil recovery. It is used for the production of confectionary and ice cream, as a viscosifier and stabilizer. It is used in human medicine as a temporary artificial skin to heal burns or surgical wounds. It is used as: an immobilization matrix for viable cells and enzymes; a microencapsulation matrix for fertilizers; a hypoallergic wound-healing tissue; an antiatherosclerotic; an antiangiogenic; and as an antimetastatic agent. In humans, cholesterol is synthesized de novo in the liver (700900 mg/day) and is also obtained through diet (300500 mg/day). Some studies have also indicated the hypocholesterolemic effect of fermented milk. This could result in the synthesis of new bile acids from cholesterol by the liver, thereby decreasing the level of circulating cholesterol (Akalin et al. It is also proposed that the assimilation of cholesterol by the bacterial cells in the intestine reduce the amount of cholesterol available for absorption, thus reducing the serum cholesterol level. The bacterial bile salt hydrolase activity decreases the resorption of bile acids by deconjugation and elimination of the deconjugated bile acids. But, the same result could not be reproduced when individual components of the oat based product were fed to rats; it was also noted that the nonropy fermented product failed to produce a cholesterol lowering effect. Kefiran could be used as a carbon source by colon microbiota leading to the production of short chain fatty acids, such as butyric acid that may modulate the immune response. Butyrate contributes to intestinal permeability and low levels of butyrate could cause leaky gut which could alter inflammatory processes (Vinolo et al. The phosphate group in the polysaccharide is believed to be responsible for the immune response (Kitazawa et al. Microbial polysaccharides of applied interest: ongoing research activities in Europe. Influence of gastrointestinal system conditions on adhesion of exopolysaccharide-producing Lactobacillus delbrueckii subsp. Exopolysaccharide-producing Streptococcus thermophilus strains as functional starter cultures in the production of fermented milks. Bifidobacterial surface-exopolysaccharide facilitates commensal-host interaction through immune modulation and pathogen protection. Biosynthesis of levan, a bacterial extracellular polysaccharide, in the yeast Saccharomyces cerevisiae. Advances in bacterial exopolysaccharides: from production to biotechnological applications. Antiviral and immunomodulatory effects of a novel bacterial exopolysaccharide of shallow marine vent origin. Mechanisms underlying the cholesterol-lowering properties of soluble dietary fibre polysaccharides. Influences of exopolysaccharide producing cultures on the quality of plain set type yogurt. Microstructure and rheology of yogurt made with cultures differing only in their ability to produce exopolysaccharides. The antitumor and antioxidative activities of polysaccharides isolated from Isaria farinosa B05. Isolation of exopolysaccharide producing Lactobacillus strains from sorghum distillery residues pickled cabbage and their antioxidant properties. Hypocholesterolaemic effects of milk-kefir and soyamilk-kefir in cholesterol-fed hamsters. Effects of an exopolysaccharide kefiran on lipids, blood pressure, blood glucose, and constipation. Fermented, ropy, oat-based products reduce cholesterol levels and stimulate the bifidobacteria flora in humans. Isolation and characterization of lactococcal bacteriophages from cultured buttermilk plants in the United States. Antioxidant activity of an exopolysaccharide purified from Lactococcus lactis subsp. Prebiotic content of bread prepared with flour from immature wheat grain and selected dextran producing lactic acid bacteria. Exopolysaccharide synthesized by Lactobacillus reuteri decreases the ability of enterotoxigenic Escherichia coli to bind to porcine erythrocytes. Exopolysaccharide activities from probiotic bifidobacterium: immunomodulatory effects (on J774A. Antioxidant activity of an exopolysaccharide isolated from Lactobacillus plantarum C88. Chapter 4 Biotransformation of Phenolics by Lactobacillus plantarum in Fermented Foods R. A diet rich in plant foods has been associated with a decreased risk of certain diseases, including cardiovascular disease and cancer. Phenolic compounds may play a role in the reported beneficial effects of plant foods as they have been extensively studied due to their diverse health benefits as antioxidants, and for preventing chronic inflammation, cardiovascular diseases, cancer, and diabetes (Landete, 2012). Phenolic compounds comprise a diverse group of molecules classified as secondary metabolites in plants that have a large range of structure and functions. They can be classified into water-soluble compounds (eg, phenolic acids) and water-insoluble compounds (eg, tannins and cell wall-bound hydroxycinnamic acids). Phenolic compounds have an aromatic ring bearing one or more hydroxyl groups and their structure may vary from that of a simple phenolic molecule to that of a complex high-molecular-mass polymer (Balasundram et al. Phenolic compounds have been considered the most important, numerous, and ubiquitous group of compounds in the plant kingdom (Naczk and Shahidi, 2004). Flavonoids account for approximately two-thirds of the dietary phenols and they are mostly present as glycosides, and partly as esters, rather than as free compounds (Haminiuk et al. In the case of the flavonoids group, when they are linked to one or more sugar molecules they are known as flavonoid glycosides, and when they are not connected to a sugar molecule they are called aglycones (Haminiuk et al. The degree of glycosylation directly affects Fermented Foods in Health and Disease Prevention. Usually, the aglycone forms are more active than the glycoside form (Hopia and Heinonen, 1999). The second most important group of phytochemicals comprises the phenolic acids, which account for most of the remaining third of the dietary polyphenols, and are present in fruits in a bound form (Haminiuk et al. These substances contain two distinguishing constitutive carbon frameworks: the hydroxybenzoic and hydroxycinnamic structures. Although the basic skeleton remains the same, the numbers and positions of the hydroxyl groups on the aromatic ring create the variety. In contrast to other phenolic compounds, the hydroxybenzoic and hydroxycinnamic acids present an acidic character owing to the presence of one carboxylic group in the molecule. Hydroxycinnamic acid compounds are mainly present as derivatives, having a C6dC3 skeleton. Ferulic acid, p-coumaric acid, and caffeic acid are some examples of this class. Common phenolic acids in this last group are gallic, vanillic, and syringic acids. Tannins are the third class of polyphenols that are found among dietary phenols and are mostly present as phenolic polymers (Haminiuk et al. Tannins are astringent and bitter substances that have the ability to precipitate proteins. Hydrolyzable tannins are complex compounds that can be degraded through pH changes, as well as by enzymatic or nonenzymatic hydrolysis into smaller fragments, mainly sugars and phenolic acids. Gallotannin or tannic acid is a type of hydrolyzable tannin found in vegetable diets which possess gallic acid as the basic unit of the polyester. Biotransformation of Phenolics by Lactobacillus plantarum Chapter 4 65 consequence of their antioxidant properties. Fruits and vegetables have most of their phytochemicals in the free or soluble conjugate forms (Acosta-Estrada et al. Bound phenolics comprise an average of 24% of the total phenolics present in these food matrices. Phenolics in the insoluble forms are covalently bound to cell wall structural components, such as cellulose, hemicellulose (eg, arabinoxylans), lignin, pectin, and structural proteins (Wong, 2006). Phenolic acids, such as hydroxycinnamic and hydroxybenzoic acids, form ether linkages with lignin through their hydroxyl groups in the aromatic ring and ester linkages with structural carbohydrates and proteins through their carboxylic group (Liu, 2007). As natural phenolic compounds often occur as glycosides, esters, or polymers the ability to function as good antioxidants is reduced (Hur et al. For this reason, biotransformation during food processing or in the gastrointestinal tract plays an essential role in phenolic bioavailability. Bound forms of phenolic compounds can be released and absorbed in the gastrointestinal tract by large intestine microorganisms and gastrointestinal enzymes (AcostaEstrada et al. In addition, there are several food processes that enhance the liberation of bound phenolics. These include fermentation and malting, as well as thermomechanical processes, such as extrusion, cooking, and alkaline hydrolysis (Acosta-Estrada et al. Food bioprocesses, such as fermentation or enzymatic hydrolysis of the plant sources and their products, appear to be an attractive means of enhancing functional activity of such phenolic antioxidants by increasing the concentration of free phenolics from their glycosides or other conjugates (Hur et al. Fermentation is preferred instead of the utilization of commercial enzymes to enhance the nutraceutical value of foods because it is relatively cheap (Acosta-Estrada et al. Composition of microbiota and its development are important factors influencing fermentation and final product quality (Hur et al. A greater understanding of phenolic metabolism by fermentation is necessary, because the fermentative microbiota probably plays a major role in the biological activity of many phenolic compounds. Some food phenolics are transformed during fermentation by the fermentative microbiota. This conversion is often essential for absorption and modulates the biological activity of these dietary compounds. As mentioned earlier, the bioavailability and effects of phenolic compounds greatly depend on their transformation by specific components of the fermentative microbiota via esterase, glucosidase, dehydroxylase, and decarboxylase activities (Selma et al. During fermentation, the grain constituents are modified by the action of both endogenous and bacterial enzymes, including esterases, xylanases, and glycosidases, thereby affecting their structure, bioactivity, and bioavailability (Table 4. Cereal-based lactic acid bacteria fermentation has been shown to increase the levels of nutrients including folates, soluble dietary fiber, and total content of phenolic compounds in cereals, and to improve protein digestibility (Hole et al. Fermentation enhanced the content of bioactive compounds in kidney beans (Limуn et al. Because fermentation improves antioxidative activity by increasing the release of phenolic compounds from plant-based foods, it is a useful method for increasing the supply of natural antioxidants. The fermentation-induced structural breakdown of the vegetal cell walls may also liberate and/or induce the synthesis of various bioactive compounds which could be responsible for the increase in total phenols after fermentation, and the increase in the observed antioxidant activity (Dordevic et al. Microbial enzymes, such as glucosidase, amylase, cellulase, chitinase, inulinase, phytase, xylanase, tannase, esterase, invertase, or lipase produced during fermentation can hydrolyze glucosides, and break down plant cell walls or starch. These enzymes play a role in disintegrating the plant cell wall matrix and consequently facilitate flavonoid extraction. Another possible Biotransformation of Phenolics by Lactobacillus plantarum Chapter 4 67 mechanism for increasing the antioxidative activity of plant-based foods by fermentation may be due to structural changes in phytochemicals. The presence of lactic acid bacteria in controlled fermentation contributes to the simple phenolic conversion and the depolymerization of high-molecular-weight phenolic compounds (Othman et al. The increase in total phenols observed after fermentation could be responsible for the increase observed in the antioxidant activity (Ng et al. As an example, the health benefits of fermented soy foods have been attributed to the antioxidant activity of specific compounds that are structurally modified or released after bacterial hydrolysis, such as the conversion of glycosylated isoflavones into their aglycones which occurs during fermentation (Hubert et al. Compared with unfermented soybean, fermented soybean foods contain more aglycones than the predominant isoflavone structures. Thus, the conversion of glucosides into their aglycone form by fermentation is a principal means of increasing antioxidative activity in plant-based foods. The isoflavones genistein and daidzein ("phytoestrogens") are much discussed because of their potential health benefits. They were reported to be hydrolyzed by -glucosidase activities of lactic acid bacteria during soy milk fermentations. Species of Lactobacillus and Bifidobacterium hydrolyzed the flavonoid -glucosides malvidin and delphinidin, which are of interest as food additives due to their antioxidant capacities (Avila et al. In contrast, it has been reported that the amount of flavonol glycosides, which account for up to 18% of the total phenolic compounds present in green tea, were reduced during tea fermentation and that this reduction in the flavonol glycosides might be due to oxidative degradation (Kim et al. Fermentation has a positive influence on the total phenolic content, however, the degree of this influence depends on the microorganism. During fermentation, the enzyme -glucosidase catalyzes the hydrolysis of glycosidic linkages in alkyl and aryl -glucosides, as well as glycosides containing only carbohydrate residues. This enzymatic activity might help the cleavage of intersugar linkages, releasing the corresponding glycosides that were hydrolyzed liberating the phenolic aglycon moieties (Martins et al. Unexpectedly, recombinant enzyme showed galactosidase activity but not glucosidase activity (Acebrуn et al. The degradation of phenolic compounds present in some plant-derived foods has been studied. When the degradation of nine phenolic compounds present in olive products was tested it was found that only oleuropein and protocatechuic acid were metabolized by L. Oleuropein was metabolized mainly to hydroxytyrosol, while protocatechuic acid was decarboxylated to catechol. Among the 10 compounds analyzed, only some hydroxycinnamic acids, gallic acid, and methyl gallate were metabolized by the L. Among the hydroxybenzoic acids assayed, only gallic and protocatechuic acids were metabolized by both cell cultures and cell-free extracts from L. Gallic acid was decarboxylated to pyrogallol, and protocatechuic acid was completely decarboxylated to catechol by L. It is interesting to note that pyrogallol, which possesses three adjacent hydroxyl groups, is the most potent radical scavenger among simple phenols (Ordoudi and Tsimidou, 2006). In relation to the metabolism of complex hydroxybenzoic acid-derived compounds, such as tannins, the enzymes involved in their metabolism in L. Vegetable tannins are phenolic compounds that are present in many fermented plant foods. On the one hand, they are beneficial to health due to their chemopreventive activities against carcinogenesis and mutagenesis, but on the other hand, they may be involved in cancer formation, hepatoxicity, or antinutritional activity. Tannins are considered nutritionally undesirable because they precipitate proteins, inhibit digestive enzymes and affect the utilization of vitamins and minerals (Chung et al. The molar mass of tannin molecules affects the tannin characteristics directly, it has been found that the higher the molecular mass of tannin molecules, the stronger the antinutritional effects and the lower the biological activities (Chung et al. Low-molecular-weight tannins are suggested to have fewer antinutrional effects and can be more readily absorbed. Tannase is used in the production of gallic acid for the synthesis of propylgallate, a potent antioxidant. It has been postulated that this enzymatic property provides an ecological advantage for this species, as it is often associated with fermentations of plant materials. This metabolic transformation implies the successive action of a tannase and a gallate decarboxylase enzyme. Controversial results were obtained about the presence of an extracellular tannase in L. The obtained results indicated that the two tannases played different physiological roles in L. The recombinant tannases were further purified and biochemically characterized (Iwamoto et al. Temperatures around 2030°C and acidic pH could be environmental conditions present on these plant fermentations. Cell-free extracts from these cultures showed the overproduction of a protein which was absent in the uninduced cultures (Jimйnez et al. Homology searches among proteins in databases identified lp 2945-like genes located within a three-gene operon which encoded the three subunits of nonoxidative aromatic acid decarboxylases (B, C, and D subunits). Experiments carried out demonstrated that LpdC is the only protein required to yield gallate decarboxylase activity, although LpdB is also essential for decarboxylase activity. Similar to tannase, which showed activity only on esters derived from gallic and protocatechuic acids, purified LpdC protein showed decarboxylase activity only against both hydroxybenzoic acids (Jimйnez et al. In contrast to tannase activity, gallate/protocatechuate decarboxylase activity is widely present among lactic acid bacteria. Apart from Enterococcus faecalis, among lactic acid bacteria, decarboxylation of aromatic acids has been described in L. Both bacterial species decarboxylate the same hydroxybenzoic acids, gallic and protocatechuic acid, and L. This substrate Biotransformation of Phenolics by Lactobacillus plantarum Chapter 4 73 specificity suggests a concomitant activity of tannase and gallate decarboxylase on specific phenolic substrates. The genes encoding inducible gallate decarboxylase (lp 2945) and tannase (lp 2956) are only 6.
Duration of 8 years Mild PrP-positive amyloid deposits in the cortex and cerebellum; no spongiform degeneration; corticospinal degeneration in the lateral and anterior pyramidal tracts; Lewy bodies in the neocortex and the substantia nigra antibiotic resistance summary cheap 250mg cefadroxil with visa. Intellectual slowing antibiotics quick guide 250mg cefadroxil with amex, behavioural change virus transmission discount cefadroxil 250mg with mastercard, extrapyramidal and cerebellar signs antibiotics for uti and bladder infections buy discount cefadroxil 250 mg, myoclonus antibiotic used for lyme disease 250 mg cefadroxil mastercard. Neuropathology Neuronal loss antibiotic prophylaxis purchase cefadroxil 250 mg with amex, spongiform change infection 2 tips order cefadroxil 250 mg with visa, gliosis and multi-centric plaques virus papiloma humano buy cheap cefadroxil 250mg online. It is mainly characterized by the presence of amyloid cores surrounded by abnormal tau-positive neurites, similar to neuritic plaques in Alzheimer disease. In addition, there are neurofibrillary tangles in the same areas of the neocortex. Autonomic dysfunction also occurs early and includes increased lacrimation, salivation, sweating, raised body temperature, and impotence in males. Endocrine abnormalities also were noted with an increase in catecholamines and cortisol and a loss of normal circadian rhythms. Ataxia, dysarthria and dysphagia are among the early signs, while cognitive functions remain relatively spared until late in the course of the illness. Cognitive functions show a lack of vigilance and attention as part of selective memory impairment. This illustrates the dramatic effect on disease phenotype that can result from a subtle change in PrP structure. In contrast, patients who are heterozygous at codon 129 have a prolonged course, present with ataxia and dysarthria, tend to have prominent cognitive impairment and seizures. The neocortex is mostly preserved in patients with disease duration of less than one year, but is focally affected by spongiosis and gliosis in patients with duration of disease longer than a year. Clinical features are determined, to a significant extent, by the number of repeats. Patients with five and more extra repeats develop the disease earlier (35 years of age on average) than patients with one to four extra repeats (67 years of age). In addition, patients with five or more extra repeats have a longer duration of illness (8 years) when compared with patients with one to four repeats (4 months). In contrast, patients having seven or more octapeptide repeats have unior multi-centric PrP amyloid plaques located in the molecular layer of the cerebellum and the cerebral gray matter. Brain tissue from patients with five, seven and eight extra repeats has transmitted the disease to primates after intracerebral inoculation. The patient had received a corneal transplant at 55 years of age because of a corneal dystrophy. Eighteen months later she developed lethargy and ataxia, followed by myoclonus, spasticity and akinetic mutism. The donor of the graft had died after a 2-month history that included ataxia, memory loss and myoclonus. Two young patients from North America had undergone electrocorticography in 1974 for intractable epilepsy. The patients developed progressive neurological disease, after a delay of 16 and 20 months respectively. The electrode probes used in both cases had previously been implanted (for two days) into the brain of a 70-year-old woman with a 4-month history of mood disturbance, ataxia, mental deterioration and involuntar y movements. The electrodes had been cleaned with benzene, disinfected with 70% ethanol and sterilized in formaldehyde between each use. It is presumed that in these cases routine sterilization procedures were insufficient to eliminate infectivity. The majority of the implicated grafts were produced by a single manufacture between 1982 and 1986. At this time, the company produced the product by pooling dura while it was undergoing processing. The hormone had been manufactured in batches, each batch containing up to 2000 pituitary glands. In addition, experiments have shown that the infectious agent can survive methods of "inactivation" used in commercial production. The use of cadaver-derived growth hormone has now been replaced by recombinant growth hormone. However, the incubation period after intracerebral exposure is shorter when compared with peripheral exposures. Cerebellar onset is more typical in peripheral exposures (including dura mater implants onto the brain surface) and dementing onset in intracerebral exposures. In addition, transmission is a rare event and it has been confirmed in only specific and limited circumstances, as described above. In addition, a number of epidemiological studies (including a meta-analysis of case-control studies) have been published. Experimental models have detected the infective agent in the blood and blood components of experimentally infected animals, transmitted infection via transfusion (rare) and transmitted infection via other routes of exposure (intracerebral inoculation). In many cases, immunocytochemistry also shows widespread distribution of PrP in a diffuse pattern within the cerebellar granular layer. Some countries have largely discontinued the use of commercial cadaver-derived dural homo22 4. Consequently, it is essential that occupational exposure be minimized wherever possible, but in particular exposure to brain and other high-risk tissues. Penetrating wounds or inoculation into mucosal tissues would logically seem to pose the highest risks. Unless more evidence accrues to the contrary, except in areas where the loss of safe donors can safely be offset, blood services should focus their efforts on known transfusion-transmitted pathogens. They should do this by providing the appropriate donor selection and screening measures that will contribute most effectively to making blood safe in their region. The mean delay from developing unsteadiness to becoming bed-bound is 6 months (range 313 months), and the median delay from becoming bed bound to death is 1. Overall, by 3 months, 93% of cases have psychiatric symptoms and 69% have neurological symptoms. Common early psychiatric features include dysphoria, withdrawal, anxiety, irritability, insomnia and loss of interest (see Figure 4. Forgetfulness (included in the data here as a psychiatric feature) is present at onset in only 12%, but developed in most patients before 8 months (median 4 months). Delusions, characteristically fleeting, are a noteworthy psychiatric feature in many cases. These usually occurred a few months into the illness, but rarely were present at onset and in others did not occur until after 1 year. Examples include seeing monsters, spiders and flying firemen and hearing voices telling the patient to commit suicide. Although a minority of cases suffer from forgetfulness or mild unsteadiness of gait from an early stage, clear neurological signs are generally not apparent for many months after disease onset (median 6, range 425). During this time, the most prominent clinical features are psychiatric disturbance or sensory symptoms or both. After the onset of overt neurological dysfunction, usually ataxia, the illness rapidly progresses (see Figure 4. Transient seizure-like episodes are only very rarely reported, often in patients taking potentially pro-epileptic medication. The initial psychiatric diagnosis in the majority of cases was depression, although in some the possibility of an organic basis was suspected, particularly in those with associated forgetfulness. In a small number of patients, a psychotic illness was suspected; rarely were psychiatric symptoms considered hysterical or functional only. The psychiatric treatment given to patients reflected these diagnoses and just over half over received antidepressants, often initially prescribed by their family doctor, and about one-sixth of cases received antipsychotic medication. About two-thirds of patients had persistent sensory symptoms and in nearly one-third of these this was an initial feature. For those cases in which this was not an initial symptom, the median delay to its occurrence was 6 months (range 211 months). The symptoms were varied and some patients complained of more than one type of sensory disturbance. Limb pain was most common and was often nonspecific and poorly localized, usually occurring in the lower limbs. Other sensor y symptoms, in order of decreasing frequency, included paraesthesia, dysaesthesia, cold feelings and numbness. Any part of the body could be affected, including the limbs, trunk, face, mouth and tongue, and the sensory disturbance could spread over time. The clinical description and results of neurophysiological investigations suggest that sensory disturbance has a central rather than peripheral origin. Formal neuropsychological examination was conducted in a minority of cases, mostly after the development of neurological symptoms and signs, and all demonstrated significant cognitive impairment, even in the rare instances when the testing was performed early in the clinical course. Liver function tests are also usually normal, but about half of cases showed abnormalities that are minor, transient or both, most likely as a result of intercurrent infection or medication. In order of decreasing frequency they were sensory disturbance, gait disturbance or incoordination, involuntary movements (tremor, myoclonus, chorea, dystonia), dysarthria, double or blurred vision, dysphagia, taste disturbance. All patients for whom there was sufficient clinical information available were noted to have involuntary movements. In order of decreasing frequency they were myoclonus, chorea, dystonia, and tremor. Other signs, in order of decreasing frequency, included pyramidal signs, upgaze paresis and primitive reflexes. Sensory abnormalities were noted on examination at some point during the illness in only about onefifth of those with sensory symptoms. These included abnormalities of joint position sense, pinprick, hyperalgesia and hyperpathia. Metabolic disorder (n=1) Other Cerebrovascular disease (n=2) Peripheral neuropathy (n=2) Vitamin B12 deficiency (n=1) Normal brain (n=1) No neuropathological diagnosis (n=1) Clinical recovery (n=4) or improvement (n=15) vasculitis (see Figure 4. The latter conditions and cerebral vasculitis are of particular importance because they are potentially treatable. The duration of illness is slightly prolonged in those carrying at least one valine allele. X-ray imaging procedures), diagnostic tests or interventions involving non-infective tissues. Based on current knowledge, isolation of patients is not necessary; they can be nursed in the open ward or at home using universal precautions. When in hospital settings, nursing in a single room is not required for infection control, but may be appropriate for compassionate reasons. Whether at home or in a hospital, patient waste should be handled according to recommended best practice. No special precautions are required for eating utensils, feeding tubes, suction tubes, bed linens, or items used in skin or bed sore care in any environment. Caregivers both in the home and health care setting should be made aware and anticipate the possibility of psychiatric symptoms. For this reason, provision of information and advice to professional and non-professional caregivers is recommended. As the disease is usually rapidly progressive, patients develop high dependency needs and require frequent assessment. It is essential to address the emotional, physical, nutritional, psychological, educational, and social needs of the patient and the associated needs of the relatives. Coordinated planning is vital in transferring care from one environment to another. Current heightened awareness requires special sensitivity to the confidentiality of written and verbal communications. Therapies aimed at palliation of any distressing symptoms, such as clonazepam or sodium valproate for myoclonus, are frequently successfully administered. Sedatives may be required for agitation, but such symptoms, if present, often abate naturally as the illness progresses. Patients are frequently given steroids, aciclovir or thiamine in the hope that they may have an occult, treatable condition such as a cerebral vasculitis, viral infection or Wernicke encephalopathy. One of the most exploited strategies for drug discovery relies on testing compounds on cellular and animal models of prion diseases. Amphotericin B (an antifungal drug) and iododoxorubicin (an anticancer agent) have been found to delay death in hamsters or mice experimentally infected with scrapie. However, these drugs are potentially toxic and needed to be injected around the time of infection, or shortly afterward, to be effective. These include drugs to block agent replication sites, polyanions, such as Dextran 500 and pentosan polysulfate, which are known to prolong the lifespan of mice infected with scrapie, and compounds that inhibit agent replication by interfering with PrP glycosylation. However, further work is essential in order to establish whether these drugs can provide an effective treatment. Quinacrine and chlorpromazine are being offered on a compassionate protocol in some countries, however, without convincing or sustained improvements in health. The reader can find further information in the guidelines prepared by various organizations on their specific websites (see Web sites of interest in Annex 5, Information resources). T It is recognized that some recommendations to ensure maximum safety to caregivers and the environment may under some circumstances be regarded as impractical. They are not adequately inactivated by most common disinfectants, or by most tissue fixatives, and some infectivity may persist under standard hospital or healthcare facility autoclaving conditions. They are also extremely resistant to high doses of ionizing and ultraviolet irradiation and some residual activity has been shown to survive for long periods in the environment. Throughout the chapter there is specific and assumed reference to country or regionspecific guidelines for matters which lie within the legal jurisdiction of that country or region, i. Readers should be familiar with such requirements for their own country or region. From these considerations it is possible to make decisions about whether any special precautions are needed. The specific recommendations are described in sections devoted to patient care, occupational injur y, laborator y investigations and management after death. They must be managed using specific precautions, which will be described in this and subsequent sections. Tears Nasal mucus Saliva Sweat Serous exudate Milk Semen Urine Faeces b Assignment of different organs and tissues to categories of high and low infectivity is chiefly based upon the frequency with which infectivity has been detectable, rather than upon quantitative assays of the level of infectivity, for which data are incomplete. Actual infectivity titres in the various human tissues other than the brain are extremely limited, but data from experimentally-infected animals generally corroborate the grouping shown in the table. No infectivity has been detected in a wide variety of other tested tissues (heart, skeletal muscle, peripheral nerve, adipose tissue, gingival tissue, intestine, adrenal gland, thyroid, prostate, testis) or in bodily secretions or excretions (urine, faeces, saliva, mucus, semen, milk, tears, sweat, serous exudate). Cutaneous exposure of intact skin or mucous membranes (except those of the eye) poses negligible risk; however, it is prudent and highly recommended to avoid such exposure when working with any high infectivity tissue. Thus, it is prudent to avoid these types of exposures when working with either low infectivity or high infectivity tissues. These could include ophthalmoscopic examinations, various types of endoscopy, vascular or urinary catheterization, and cardiac or pulmonary function tests. In general, these procedures may be conducted without any special precautions, as most tissues with which the instruments come in contact contain no detectable infectivity (see Figure 6. A conservative approach would nevertheless try to schedule such patients at the end of the day to allow more strict environmental decontamination and instrument cleaning. When there is known exposure to high- or low-infectivity tissues, the instruments should be subjected to the strictest form of decontamination procedure that can be tolerated by the instrument. Detailed information on disposal of medical waste is provided in this chapter, Section 6. Every effort should be made to plan carefully not only the procedure, but also the practicalities surrounding the procedure. All staff directly involved in these procedures or in the subsequent reprocessing or disposal of potentially contaminated items, should be aware of the recommended precautions, and be adequately trained. Staff must adhere to protocols that identify specifics regarding pre-operative, perioperative and post-operative management of the patient, disposable materials, including bandages and sponges, and reusable materials. Ancillary staff, such as laboratory and central instrument cleaning personnel, must be informed and appropriate training provided. Recommendations for decontamination of equipment and environment, and for disposal of infectious waste should be followed. Reusable dental broaches and burrs that may have become contaminated with neurovascular tissue should either be destroyed after use (by incineration) or decontaminated by a method listed in Annex 1. Schedule procedures involving neurovascular tissue at end of day to permit more extensive cleaning and decontamination. Instruments should be cleaned as soon as possible after use to minimize adherence of tissues, blood and body fluids. Avoid mixing instruments used on no-detectableinfectivity tissues with those used on high- and lowinfectivity tissues. Cover work surfaces with disposable material, which can then be removed and incinerated; otherwise clean and decontaminate underlying surfaces thoroughly, using recommended decontamination procedures in Section 6. Determination of which method to use is based upon the infectivity level of the tissue and the way in which instruments will subsequently be reused. For example, where surgical instruments contact high infectivity tissues, singleuse surgical instruments are strongly recommended. If single-use instruments are not available, maximum safety is attained by destruction of reusable instruments. Where destruction is not practical, reusable instruments must be handled as detailed in Figure 6. This exception reflects the higher risk of transmission to any person on whom the instruments would be reused for the procedure of lumbar puncture. They should be transferred to the sterilization department as soon as possible after use, and treated by a method listed in Annex 4. A designated person who is familiar with this guideline should be responsible for the transfer and subsequent management. Items for quarantine should be cleaned by the best nondestructive method given in Section 6. Reusable instruments should be handled as for any other clinical procedure (Figures 6.
This method assumes that the products * - themselves are being maintained at safe temperatures and that handles do not contaminate the products antibiotic interactions order cefadroxil 250 mg visa. This method implies that the utensil has been cleaned of ready to eat food debris by a sanitized wiping cloth antimicrobial wound cleanser cefadroxil 250 mg low cost. This method implies that the flushing action of the water is sufficient to rinse food particles down the drain with volumes of water adequate to reduce concentrations of bacteria to safe levels antimicrobial hand sanitizer cheap 250 mg cefadroxil with mastercard. In this case virus alert buy cefadroxil 250mg with visa, the temperature of the water prevents the growth of bacteria antibiotic impregnated beads buy cefadroxil 250mg, and the water need not be running antibiotics for face rash 250mg cefadroxil free shipping. From a practical side antimicrobial resistance in developing countries cefadroxil 250 mg discount, the water must be changed frequently and the utensil cleaned free of food particles regularly infection vs virus purchase 250mg cefadroxil overnight delivery. In-use utensils are prohibited from being placed in standing water at room temperature, and from being left at room temperatures while soiled with potentially hazardous food remains. Utensils for dispensing salt, sugar, and margarine or utensils such as rolling pins, basting brushes, and the like are simply required to be stored so as to minimize the contact that hands would have with the foods being prepared. Confrolled use of disposable gloves Surfaces of gloves become contaminated in the same way as hands, from the human body, from foods, and from the contaminated surfaces of equipment and utensils. Changing single-use gloves at a frequency that parallels the hand washing regimen and sanitizing regimen is necessary. Observation of employees will often reveal that employees either change gloves when it is unnecessary or change gloves too infrequently. Therefore, hand washing is essential when changing gloves and at regular intervals (Larson, 1989). Chemical contamination control Chemical contamination may be introduced into food during preparation if polishes, detergents, sanitizers, lubricants, and cleaners are not properly used and not safely applied on the working surfaces of equipment and utensils. Placing dilute sanitizer solutions near equipment is not hazardous; however, placement of concentrated sanitizers in jugs and other containers on or above food equipment is potentially hazardous. Many types of detergents and cleaners are used to clean equipment and utensils, and, although not highly toxic, they may cause exposures if residues remain. Sanitizers should be used in very low concentrations: exceeding these concentrations will possibly expose consumers to potentially toxic chemicals. Only food-grade lubricants should be used on slicers, rotisseries, rack conveyors, and other food processing equipment. Handling of grease Grease-laden vapors are produced when foods are fried, grilled, or cooked in open containers. Crease on surfaces such as the stove hood or fixed fire extinguisher piping can contaminate foods when heavy accumulation occurs. Cleaning of surfaces where grease accumulates is necessary for sanctation fire safety. Prevention and control of contamination from people Medical certification: Health status of employees may vary on even a daily basis. A once yearly physical may reveal chronic conditions or carrier status of a few infections agents such as Salmonella. Exclusion and restriction Infected workers are a leading cause of foodborne illness. Effective hand washing may reduce the level of pathogens significantly, but highly virulent viral agents, such as Norwalk virus and hepatitis A, may not be entirely removed (Guzewich, 1996). This is because the cost of vaccinating food workers may be low compared with the cost of immunizing whole populations or the administration of postexposure prophylaxis to patrons. Many public health agencies feel that food workers should be encouraged to get vaccinated under these conditions because this is for their own protection. Vaccination greatly reduces the risk of hepatitis A transmission during outbreaks. Under normal conditions, restriction or exclusion of ill workers should be the first line of defense for bacterial or fecal agents. But this can only be accomplished if employees are obviously ill or if they report their symptoms to management as required. Employees must report infected cuts, wounds, burns, respiratory infections, gastrointestinal symptoms, and jaundice. Once management knows that an employee has symptoms of gastroenteritis or another communicable condition, either restriction of the employee to nonfood contact duties or exclusion of the employee from the premises must follow. Employees are placed on restriction and may not handle food, clean equipment, or clean utensils when symptoms of communicable disease exist and no diagnosis from a physician is available. Food service workers unable to afford health insurance are not likely to seek conventional medical attention and are unlikely to be diagnosed. Management policies may also discourage employees from calling in sick, and managers may even feel the need to pressure employees to report to work regardless of their health status. Personal hygiene practices During the period 1988-1992, the second most commonly reported practice that contributed to foodborne disease was poor personal hygiene of food workers, reported in 36% of outbreaks (Bean et al. Effective systems for personal hygiene are based on an understanding of the source and nature of contamination. But the most important source of contamination is the contamination that people carry inside their digestive tract. It has long been known that food workers can transmit pathogens to food after using the bathroom if good personal hygiene is not maintained (Crisley and Foter, 1965). An effective hand washing program is facilitated when personal hygiene protocols are clearly described and management takes an active role in ensuring that they are always being followed. Once developed, the program must be communicated and implemented consistently and effectively. The recommended elements of a hand washing program include ongoing training, a monitoring program, corrective actions, and a reward system. The overall effectiveness of training and implementation can be enhanced by the use of visual aids such as posters or demonstrations with currently available training aids [e. Additionally, sinks are available that keep track of usage and/or that turn on and off with sensors. Therefore, it is best to minimize hand contact with door handles, sink faucets, and hand drying devices. Automatic valves on sinks eliminate the need to touch the sink area, thus reducing the potential for recontamination of hands after washing. The use of a hand sanitizer and/or antibacterial detergents or soap is recommended by many health authorities and even required by some jurisdictions. Proponents argue that they reduce the microbial burden on the hands, making disease transmission less likely (Larson, 1995). Others have found that although bacteria are reduced, the spectrum of bacteria killed is broad and both resident microflora and transient populations are reduced simultaneously (Mahl, 1978). Furthermore, the use of hand sanitizers as a replacement for washing the hands is deemed an unhygienic practice by most health jurisdictions and is prohibited in the 1999 Food Code. As mentioned, continuous-feed paper towels reduce the potential for recontamination of the hands, and the scrubbing action and friction of the towel further reduces microorganisms. There is some indication that blow dryers may harbor microorganisms and deposit them on hands during their use (Restiano and Wind, 1990). These small basin sinks must be located at strategic points throughout the establishment. All food preparation areas must be provided with at least one easily accessible and conveniently located hand lavatory. All bathrooms must have at least one hand washing facility located within the bathroom or immediately adjacent to it. Remote ware washing areas should also be provided with a hand sink, and bars require a hand sink, as well. There is no definite rule as to how many sinks are required or their placement in terms of square footage or distance apart. Although each commercial food facility is different in its requirements, the flow of foods through the operation provides a good basis for determining where and when hands are likely to be contaminated and the proper location for hand washing sinks. Most regulatory agencies do not list the three-compartment sink or the utility sink as acceptable for hand washing. Because three-compartment sinks are generally used for preparing foods as well as cleaning utensils, employees in the habit of washing their hands in such sinks will eventually contaminate a food item or a utensil. The utility sink is unacceptable because surfaces are liable to be contaminated and may result in recontamination of the hands. Posting instructive signs at all hand washing sinks is a simple method of designating the proper sink to use. Signs are available from many health authorities because many jurisdictions provide one for posting in the restroom. The practice of designating a hand washing lavatory with a sign should be extended into the food preparation area as well. Knowing when to wash requires not only recognizing the sources of contamination-the person, raw animal foods, supplies, and contaminated surfaces in the environment-but also recognizing when contact has been made with them. Before beginning work Before handling foods After touching bare human body parts other than clean hands and clean arms After using the restroom After handling support animals After coughing. The greatest potential exposure to pathogens probably occurs during defecation, so personal hygiene after using the toilet is the most critical time to wash hands. The specific times when it is mandatory to wash hands according to the Food Code are listed in Table 26. It is also beneficial to require employees to wash whenever they return to the kitchen. Locating a hand washing station near the entrance to the kitchen makes hand washing at this point observable for the manager and convenient for the employee. Some commercial food service establishments require their employees to wash their hands at set time intervals as a minimum measure. This ensures that employees will wash their hands at least a minimum number of times but does not ensure that employees will wash when it is necessary. Employees with contaminated hands may actually postpone hand washing until the designated time, thereby increasing the potential for the spread of contamination. Although the Food Code and most local jurisdictions do not list "after handling money" as a necessary time to wash hands, coins and bills are noticeably soiled. Money as a substrate has recently been shown to allow survival of pathogenic organisms for several hours (Doyle). Consumers view the handling of money and subsequent contact with foods as an unacceptable hygienic practice, and for these reasons it is advisable to wash hands at regular intervals when handling money or to designate a separate person as a cashier. Hands must be washed thoroughly to reduce the level of contamination by an order of five logarythmns; this five log reduction (1 O 5 reduction) greatly lessens the likelihood of a consumer being exposed to an infectious dose of a pathogen. Hand washing in a sense is a misnomer because fecal pathogens tend to be collected on fingertips, especially in the fingernail and cuticle area (McGinley et al. A typical fecal smear on the side of a finger may be on the order of 1/1000th of a gram; but this very small, inconspicuous amount of waste may contain millions of viral particles. However, with many agents, an effective hand washing program will reduce the potential for disease transmission greatly. In addition to improper hand washing, food handlers can also contaminate food through other unhygienic practices (see partial list in Table 26. Such practices provide a secondary route of exposure to pathogens as well as physical or chemical contamination, give the appearance of poor sanitation to both customers and other employees, and detract from the aesthetic enjoyment of the dining experience, and are they frequently cited as poor hygienic practices by regulatory agencies and in consumer complaints. These poor practices are nevertheless important and should be a part of the good manufacturing practices or standard operating procedures for a commercial food service establishment. In addition to microbiological contamination, workers can easily drop foreign objects into foods. Special precautions should be taken with small objects commonly worn or carried by people. Foreign objects that originate with people include jewelry, pen tops, buttons, threads, hairpins, name tags, watch parts, false fingernails, hair, fingernail polish, matches, cigarette butts, ashes, chewing gum, and toothpicks. Management policies governing the habits and dress of employees are needed to control contamination. Because employees may feel discriminated against R hen advised about rules of dress, hairstyles, and personal ornamentation, clear and uniform policies are important. Hair nets or caps are the best hair restraints; hair may also fall out of beards and mustaches, and specialized coverings and nets are available. Simple precautions such as wearing a uniform instead of street clothes help to standardize controls; using only push button pens instead of pens with caps and prohibiting any jewelry except a simple wedding band are other common sense controls. Employees should never smoke while in the food preparation or storage areas, nor should they use toothpicks while working around foods. Maintenance of hand washing sinks the complete hand wash station includes a hand sink with hot and cold running water under pressure (minimum of 20 Ib. The sink should be unobstructed at all times, and it should be kept clean and in good repair. Employees will not take the hand washing program seriously if the necessary items are not always provided or the sink is not working. As stated above, hand sinks with automatic valves are easily installed, there are models that count the number of washes, and there are even automatic soap and sanitizer dispensers. By utilizing the latest technology, commercial food service establishments may be able to increase compliance with hand washing programs. Such barriers include utensils such as deli paper, spoons, spatulas, forks, and gloves. Gloving is preferred to hand washing as a means of interrupting the orofecal transmission pathway by some jurisdictions, most notably the state of New York. Gloves have fallen into disrepute because employees, once gloved, may see themselves as protected and be more prone to touching contaminated objects without changing gloves or washing hands (Fendler et al. Because of the potential "false sense of security," many restaurants are opposed to any mandatory no bare hand contact provisions and commonly but mistakenly refer to these laws as "glove rules. The state of Florida has adopted an "Alternative Operation Procedure" for commercial food service facilities under their jurisdiction. Florida was the first state to legislate a plan to address the Food Code provision for an alternate means of compliance to the no bare hand contact provisions. The Florida plan as outlined below forms a basis for other states to establish similar programs. Under these programs, commercial food service operations must develop an effective plan to control contamination through hand washing. Alternative plans must include a description of all controls, as well as where, when, and how to wash. Food handler training and management practices Foods handled by untrained staff are assumed to be contaminated, so training is essential. Leadership and motivation are required if training is going to accomplish the goal of providing safe food; this is especially true as regards personal hygiene practices. Managers who demonstrate good hygiene will be followed, and unhygienic practices by managers tend reinforce bad habits in employees. Body fluid precautions Saliva, perspiration, and blood may carry pathogens such as Staphylococcus aureus, Streptococcus pyogenes, hepatitis A virus and hepatitis B virus. Precautions to guard against introduction of saliva into food include not eating or smoking in food areas, but the Food Code does allow the use of a closed vessel and a straw for drinking beverages. Perspiration is unavoidable in high-heat areas of many food service kitchens, especially in the summer. Required Components of Alternate Means of Compliance with No Bare Hand Contact Provisions (State of Florida). The plan must include a description of * All hand washing controls; and * Hand washing protocols (when. Employees must be in compliance with the Employee Health section of the Food Code. Sinks designated as hand-washing sinks must always be provided with hand soap, an approved drying device, and hot (1 1Oo) and cold water under pressure. Managers must train the employees in the standards of the Food Code and the facilities policies and then make sure they are following the policies. Corrective actions must be taken when deviations occur; most importantly, foods Contaminated by workers must be discarded. All training materials and the plan itself must be at the establishment and available for inspection by regulatory staff: - mend a maximum kitchen temperature, it is advisable to keep temperatures in all work areas relatively comfortable for food handlers and to provide adequate ventilation. Wiping of perspiration should be done in a sanitary manner with a paper towel that is disposed of promptly. If an injury takes place involving cuts, wounds, or burns, all activity in the work area should cease and the employee should be attended to . N o employee should handle any item contaminated with blood with his/her bare hands. Whether visibly contaminated or not, all utensils must be removed from the affected area and taken to the ware washing area for cleaning and sanitizing. All containerized foods must be inspected, and if foods are suspected of being contaminated, they must be thrown out. However, the public will react very emotionally to any foods contaminated by human blood. Wounds bandaged Infected cuts and other skin lesions may harbor large numbers of bacteria, especially Stuphylococcus aureus (Burton, 1992). Employees must be placed on restriction if they have any infections on the hands or exposed areas of the face or arms. An exception can be made if an employee has a bandage on the hand or finger, if an impervious barrier (commonly called a finger cot) protects the bandage, and if the hand is also placed inside a sanitary glove. Prevention and control of contamination from environmental hazards Potable water In addition to cooking purposes and beverages, water also serves several other culinary and sanitary functions including ice making, dilution of chemicals, hand washing and ware washing, and general cleaning. Water is an integral part of the foods served, of the food service environment, and of food preparation. The relationship between microbiological contamination of water and human illness has been well documented throughout history. Recently, a waterborne outbreak at a New York county fair resulted in nearly 100 confirmed cases of Cumpylobacter and E. Any water used in a food service facility must be potable (considered safe from microbiological and chemical hazards) by existing regulations. Wells serving commercial food service establishments must have permits as public drinking water wells under most regulatory programs. Most authorities require continuous chlorination of water supplies for disinfecting.
