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The paper is organized under the old Roman motto veni buy viagra extra dosage in united states online what causes erectile dysfunction, vidi buy viagra extra dosage 200mg erectile dysfunction treatment natural way, vici in three parts purchase generic viagra extra dosage online erectile dysfunction lexapro, namely: veni — coming from a successful history cheap viagra extra dosage 130 mg free shipping erectile dysfunction latest medicine; vidi — examining new challenges; and vici — successfully moving towards an international regime for radiation safety in medicine. It is noted, however, that his opinions in this paper do not necessarily reflect those of these bodies. An international radiological protection regime would eventually evolve under the aegis of several prestigious international organizations, becoming a network of science, paradigm and regulatory standards. What follows is a summary account of this successful history, with a focus on protection in medicine, particularly of patients. The early stages At the beginning of the twentieth century, the knowledge of radiation and its effects was limited and the main concern was protecting the staff practising the medical use of the sole radiations being employed at that early time, namely X rays and radium emissions. Those early recommendations state that: “the dangers of over-exposure to X rays and radium can be avoided by the provision of adequate protection and suitable working conditions. It is the duty of those in charge of X ray and radium departments to ensure such conditions for their personnel” (para. That early recommendation states that “screening stands and couches should provide adequate arrangements for protecting the operator against scattered radiation from the patient” (para. The early advice included some curious counsel on ergonomics, such as that X ray departments should not be situated below groundfloor level and that all rooms (including dark rooms) should be provided with windows affording good natural lighting and ready facilities for admitting sunshine and fresh air whenever possible, and with adequate exhaust ventilation capable of renewing the air of the room not less than 10 times an hour, and with air inlets and outlets arranged to afford cross-wise ventilation of the room, and, surprisingly, they should preferably be decorated in light colours (paras 3–6 of Ref. The Commission recognizes “that in medical procedures, exposure of the patient to primary radiation is generally limited to parts of the body, but the whole body is exposed to some extent to stray radiation. Accordingly, it recommended that “the medical profession exercise great care in the use of ionizing radiation in order that the gonad dose received by individuals before the end of their reproductive periods be kept at the minimum value consistent with medical requirements”. Moreover, concerning the exposure of patients for medical reasons, the Commission believed that “it would not be possible to make specific recommendations on dose limitation that would be appropriate for all examinations on individual patients”. The Commission also emphasized that the term ‘medical exposure’ referred “to the exposure of patients in the course of medical procedures and not to the exposure of the personnel conducting or incidentally associated with such procedures” (para. On the other hand, already at that time, the Commission started to show growing concern for the exposure of patients. It emphasized “the need for limiting the doses from radiological procedures to the minimum amount consistent with the medical benefit to the patient” (para. The Commission noted that medical exposures constituted already at that time and for the foreseeable future “the main source of population exposure”. Since it was considered likely that in most countries the number of persons medically exposed would increase, owing to the development of new procedures as well as to improved conditions for medical care, the Commission judged “increasingly important that these technological improvements should be matched by appropriate consideration of the radiation protection of the patient” (para. The Commission also re-emphasized that “careful attention to techniques would, in many cases, result in a considerable reduction of the dose due to medical procedures, without impairment of their value”. To achieve this reduction, the Commission pointed out “the value of adequate training in radiological protection for all persons who administer radiation exposures to patients” (para. These recommendations provide primary general recommendations on medical uses of radiation. For diagnostics, the recommendations covered X ray diagnostic installations, fluoroscopy, radiography, photofluorography, dental radiography and diagnostic uses of radioactive substances. For therapy, it covered beam therapy, conventional X ray therapy, superficial X ray therapy, ‘megavolt’ X ray and particle beam therapy, sealed source beam therapy, non-collimated sealed source therapy, and therapy with unsealed sources. It also generally addressed, perhaps for the first time, the issue of protection of patients. The report collated information necessary “for an adequate understanding of the principles and practice of protection of the patient in the widest sense”. It was recognized that the achievement of this purpose “was not within the scope of a single discipline, but requires a multidisciplinary effort by all who instigate X ray investigations, by those in any way concerned with the use of X ray diagnostic equipment and techniques, and by those responsible for the relevant educational programmes”. They re-emphasized protection against medical exposures, which were redefined as “the intentional exposure of patients for diagnostic and therapeutic purposes, and to the exposures resulting from the artificial replacement of body organs or functions (e. It is equally important that this assessment be made against a background of adequate knowledge of the physical properties and the biological effects of ionizing radiation. It is also necessary to consider alternative therapeutic procedures and to compare their effectiveness and their dangers with those associated with radiological treatment. It intended to guide radiologists and others concerned with diagnostic radiology with regard to the factors that influence radiation doses and, hence, radiation risks from different types of X ray examination. Recognizing that the protection of the patient in radiotherapy requires, uniquely, not the avoidance of radiation exposure or even the avoidance of risk of severe damage to some tissues, but rather achieving the optimal balance between the efficacy of sterilizing the malignant growth and minimizing treatment related complications by keeping radiation doses as low as reasonably achievable, the recommendations presented a broad overview useful to all involved in the proper therapeutic application of radiation. The new recommendations were very detailed and comprehensive and are still widely used today. Exposure of an individual to other sources, such as stray radiation from the diagnosis or treatment of other persons, is not included in medical exposure. Exposures incurred by volunteers as part of a programme of biomedical research are also dealt with in this document on the same basis as medical exposure” (para. They address the issue of dose limits in medical exposure indicating that: “they are usually intended to provide a direct benefit to the exposed individual. If the practice is justified and the protection optimised, the dose in the patient will be as low as is compatible with the medical purposes. Any further application of limits might be to the patient’s detriment” and, therefore, recommending that “dose limits should not be applied to medical exposures”, but introducing the concept of dose constraints (para. Furthermore, each increment of dose resulting from occupational or public exposure results in an increment of detriment that is, to a large extent, unaffected by the medical doses” (para. The recommendations also assessed, perhaps for the first time, the issue of medical exposure of pregnant women. It further considered that: “a pregnant patient is likely to know, or at least suspect, that she is pregnant after one missed menstruation, so the necessary information on possible pregnancy can, and should, be obtained from the patient herself. If the most recent expected menstruation has been missed, and there is no other relevant information, the woman should be assumed to be pregnant. The question of dosimetry in medical exposure is also addressed indicating that: “the assessment of doses in medical exposure, i. In diagnostic radiology, there is rarely a need for routine assessment of doses, but periodic measurements should be made to check the performance of equipment and to encourage the optimisation of protection. In nuclear medicine, the administered activity should always be recorded and the doses, based on standard models, will then be readily available” (para. However, each procedure, either diagnostic or therapeutic, is subject to a separate decision, so that there is an opportunity to apply a further, case-by-case, justification for each procedure. This will not be necessary for simple diagnostic procedures based on common indications, but may be important for complex investigations and for therapy” (para. They also recognize that: “there is considerable scope for dose reductions in diagnostic radiology using the techniques of optimisation of protection. Consideration should be given to the use of dose constraints, or investigation levels, selected by the appropriate professional or regulatory agency, for application in some common diagnostic procedures. They should be applied with flexibility to allow higher doses where indicated by sound clinical judgement” (para. They recalled again that “medical exposures are usually intended to provide a direct benefit to the exposed individual. If the practice is justified and the protection optimised, the dose in the patient will be as low as is compatible with the medical purposes” (para. Further, it is not appropriate to include the doses incurred by patients in the course of diagnostic examinations or therapy when considering compliance with dose limits applied to occupational or public exposures” (para.
For patients to act so that staff have enough time to think about what they are effectively in this capacity buy discount viagra extra dosage 200mg on line erectile dysfunction caused by fatigue, however 130mg viagra extra dosage fast delivery medication that causes erectile dysfunction, requires that physi- doing discount viagra extra dosage 150 mg with amex erectile dysfunction causes medscape. Minimize errors related to sleep deprivation by at- cians orient them appropriately and reformulate purchase 120mg viagra extra dosage free shipping erectile dysfunction desensitization, to some tention to work hour limits, and allowing staff naps if extent, certain aspects of the traditional relationship be- needed. Two new roles for patients to help reduce the chances for diagnostic error are proposed below. Take advantage of sugges- tions from the human-factors literature on how to improve Be Watchdogs for Cognitive Errors the detection of abnormal results. For example, graphic Traditionally, physicians share their initial impressions with displays that show trends make it more likely that clinicians a new patient, but only to a limited extent. Sometimes the will detect abnormalities compared with single reports or tab- suspected diagnosis isn’t explicitly mentioned, and the pa- ulated lists; use of these tools could allow more timely appre- tient is simply told what tests to have done or what treat- ciation of such matters as falling hematocrits or progressively ment will be used. Computer-aided per- checking for cognitive errors if they were given more in- ception might help reduce diagnostic errors (e. Controlled tri- its probability, and instructions on what to expect if this is als have shown that use of a computer algorithm can im- correct. They should be told what to watch for in the Graber A Safer Future: Measures for Timely Accurate Medical Diagnosis S45 Table 1 Recommendations to reduce diagnostic errors in medicine: stakeholders and their roles Direct and Major Role Physicians ● Improve clinical reasoning skills and metacognition ● Practice reﬂectively and insist on feedback to improve calibration ● Use your team and consultants, but avoid groupthink ● Encourage second opinions ● Avoid system ﬂaws that contribute to error ● Involve the patient and insist on follow-up ● Specialize ● Take advantage of decison-support resources Healthcare organizations ● Promote a culture of safety ● Address common system ﬂaws that enable mistakes —Lost tests —Unavailable experts —Communication barriers —Weak coordination of care ● Provide cognitive aids and decision support resources ● Encourage consultation and second opinions ● Develop ways to allow effective and timely feedback Patients ● Be good historians, accurate record keepers, and good storytellers ● Ask what to expect and how to report deviations ● Ensure receipt of results of all important tests Indirect and Supplemental Role Oversight organizations ● Establish expectations for organizations to promote accurate and timely diagnosis ● Encourage organizations to promote and enhance —Feedback —Availability of expertise —Fail-safe communication of test results Medical media ● Ensure an adequate balance of articles and editorials directed at diagnostic error ● Promote a culture of safety and open discussion of errors and programs that aim to reduce error Funding agencies ● Ensure research portfolio is balanced to include studies on understanding and reducing diagnostic error Patient safety organizations ● Focus attention on diagnostic error ● Bring together stakeholders interested to reduce errors ● Ensure balanced attention to the issue in conferences and media releases Lay media ● Desensationalize medical errors ● Promote an atmosphere that allows dialogue and understanding ● Help educate patients on how to avoid diagnostic error upcoming days, weeks, and months, and when and how to nated, and all medical records would be available and ac- convey any discrepancies to the provider. Until then, the patient can play a valuable role in If there is no clear diagnosis, this too should be con- combating errors related to latent ﬂaws in our healthcare veyed. Patients can and should function as conﬁdence and certainty, but an honest disclosure of uncer- back-ups in this regard. They should always be given their tainty and the probabilistic nature of diagnosis is probably a test results, progress notes, discharge summaries, and lists better approach in the long run. In the absence of reliable and would be more comfortable asking questions such as “What comprehensive care coordination, there is no better person else could this be? Healthcare organizations by ne- health services research protocols to better understand these cessity pay attention to Joint Commission expectations; errors and how to address them. In the proper order of these expectations should be expanded to include the many things, our knowledge of diagnostic error will increase other organizational factors that have an impact on diagnos- enough to suggest solutions, and patient safety leaders and tic error, such as encouraging feedback pathways and en- leading healthcare organizations will begin to outline goals suring the consistent availability of appropriate expertise. A measure of progress will be the extent to ther the cause of accurate and timely diagnosis by drawing which both physicians and patients come to understand the attention to this issue and ensuring that diagnostic error key roles they each can play to reduce diagnostic error rates. For the good of all those who are affected by diagnostic The media also must acknowledge a responsibility to pro- errors, these processes must start now. If there is anything to be learned from how aviation has improved the safety of air travel, it is the lesson of contin- Acknowledgements uous learning, not only from disasters but also from simple observation of near misses. The media could substantially This work was supported in part from a grant from the aid this effort in medicine by emphasizing the role of learn- National Patient Safety Foundation. Berner, EdD, for review of the manuscript and to Grace Thus far, funding agencies have underemphasized diag- Garey and Mary Lou Glazer for their assistance. This type of error is not regarded as one of Veterans Affairs Medical Center, Northport, New York, and 7 the low-hanging fruit. If the funding were avail- afﬁliation with a corporate organization or a manufacturer able, applications would follow. Patient safety organizations could play a substantial role in advancing diagnostic accuracy and timeliness simply by References bringing attention to this issue. This could take the form of dedicated conferences, or perhaps simply advancing diag- 1. Overconﬁdence as a cause of diagnostic error in nostic error as a featured theme at patient safety conferences medicine. Diagnostic error in internal med- lem, these forums play an invaluable role in bringing to- icine. Jt Comm J working and synergies that can more rapidly lead the ﬁeld Qual Patient Saf. Jt Comm J human factors approaches, observational techniques, or Qual Patient Saf. Translation Véronique Grouzard and Caroline Lopez-Vazquez Design and layout Evelyne Laissu Published by Médecins Sans Frontières © Médecins Sans Frontières, 2016 All rights reserved for all countries. No reproduction, translation and adaptation may be done without the prior permission of the Copyright owner. In 1981, the World Health Organization established the Action Programme on Essential Drugs to support countries to implementing national drug policies and to work towards rational use of drugs. Appropriate tools are critical to the effective implementation of essential drugs policies. Designed to give practical, concise information to physicians, pharmacists and nurses, this “Essential drugs - practical guidelines” is an important contribution from Médecins Sans Frontières to improve the rational use of drugs, which will be a continuing challenge in the coming years. Quick Director, Essential Drugs and Other medicines World Health Organization Foreword This guide is not a dictionary of pharmacological agents. It is a practical manual intended for health professionals, physicians, pharmacists, nurses and health auxiliaries involved in curative care and drug management. This manual is not only used by Médecins Sans Frontières, but also in a wide range of other programmes and contexts. These medicines have been included in this guide by entries marked by a grey diagonal line. The entries are classified according to the route of administration and in alphabetical order. This classification reflects the drug management system proposed in this manual (see Organization and management of a pharmacy). Only the main contra-indications, adverse effects, precautions and drug interactions of each drug have been indicated in this manual. Concerning antiretrovirals, the interactions are too many to be listed: it is therefore essential to refer to specialised literature. This manual is a collective effort by medical professionals from many disciplines, all with field experience. Despite all efforts, it is possible that certain errors may have been overlooked in this manual. The authors would be grateful for any comments or criticisms to ensure that this manual continues to evolve and remains adapted to the reality of the field. As treatment protocols are constantly changing, medical staff are encouraged to check this website for updates of this edition. Dosage Prescription tables showing average dosage in drug units (tablets, ampoules etc. Dosage for children are expressed in milligrams per kilogram per day (mg/kg/day) for most drugs. For certain symptomatic drugs, dosage is expressed in milligrams per kilogram per dose (mg/kg/dose).
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Computerization focused on assembling the information needed to bill for the hospital’s diverse clinical services buy cheap viagra extra dosage 150mg line erectile dysfunction treatment delhi. This department-by-department approach is some- 48 Digital Medicine times called “functional computing buy viagra extra dosage 150mg with visa impotence back pain,” as each function demanded and got its own computer system buy viagra extra dosage online now xarelto impotence. Minicomputers buy 130mg viagra extra dosage with amex erectile dysfunction doctor in miami, followed rapidly by personal computers, made department-based functional computing suddenly affordable. Hospitals began acquir- ing minicomputers, and then personal computers and servers, by the freight-car load. This is because the easy availability of systems based on personal computers and small servers reinforced the fragmentation of the hospital itself. Each profession or technical function in the hospital has its own department (a large hospital may have as many as 80 departments). Mainframe computers were so expensive that almost no hospital could afford its own. So it made economic sense for hospitals to employ a time-sharing, remote computing model. The fact that tomorrow’s computer systems will employ a network model recapitulates the ﬁrst 15 years of hospital computing history. Hospitals 49 In theory, all these professionals work together both in patient care and in supporting administrative activities. In practical reality, in many hospitals, collaboration between professional departments is grudging at best. Through the clinical and support departments they control, professions in the hospital compete for resources and control over patients. Furthermore, physicians, who control where patients are cared for, are increasingly directing patients with less complex illnesses to settings they control, like surgi-centers and freestanding heart hospitals. The boundaries separating the hospital from other caregivers are constantly shifting, due in major part to economic incentives and other nonclinical factors. Internal competition among hospital departments and the need to compete with freestanding facilities (like surgi-centers and heart hospitals, many of which have physician investors) results in an unseemly clamor for capital spending. Physicians who are em- ployees (and one-third are employed by someone, according to Amer- ican Medical Association data) tend to be employed by physician- dominated entities (group practices, academic faculty practice plans), which are organizationally distinct from the hospital. Because 83 percent of physicians’ records are in paper form, building interfaces from the hospital or other physicians’ ofﬁces to reach them is technically impossible. The hospital-physician clinical information boundary is like the blood- brain barrier in the body—a virtually impermeable boundary that traps information on either side that is needed to render safe health- care. For all these reasons, short of running a large urban school sys- tem, running a hospital may be one of the most demanding and frustrating jobs in the entire economy. In the political wheeling and dealing, often the vision of a future information architecture that works for pa- tients and physicians gets lost in the struggle to accommodate the historical culture of the hospital and to meet the short-term needs of its departments. Fragmentation Affects Patients Departmental records were not organized primarily to support or coordinate patient care, which inevitably involves multiple depart- ments. Rather, departmental record-keeping systems were created to support billing for the department’s services. Each department had its own registration and scheduling function; each departmental system assigned the patient a different identiﬁcation number. This is why, until very recently, a multidepartment hospital visit required a patient to re-register at each stop. In each location, clerks handed patients clipboards with forms that asked questions such as their social security number, mother’s maiden name, and health history. Each time they visited, patients were asked for the same information yet again, as if they were strangers. In many cases, the information was inaccessible in a physician’s ofﬁce and needed to be Hospitals 51 duplicated in the hospital. In this fragmented information world, crucial information (like what drugs patients are allergic to, what happened the last time they were hospitalized, or what their blood type is) often was very difﬁcult to obtain at the moment in time in which patients were in the ofﬁce to inﬂuence and guide their care. Moreover, if the hospital wants the dozen or more separate pa- tient records for each patient to actually come together, it must hire a consulting ﬁrm to provide “systems integration. Each time the hospital adds a new computer system, someone must write custom software code to get the new system to talk to the other, older systems. In enterprisewide computing, the hospital has a single (digital) clinical record, a single patient identiﬁer that every department and professional uses, a common repository for clinical and ﬁnancial information, and an ability to retrieve that information quickly anywhere in the organization that it is needed. The problem is that replacing all the information systems in a hospital is costly and painful. Kleinke wrote in an oft- quoted 1998 analysis, enterprise software in hospitals has been a costly disappointment for most institutions. Certainly this has been a real (and continuing) problem—vendors promising complex applica- tions that are not completed. However, I believe the problem is larger than the reality of how hard it is to build complex tools that work. The fact that it has been so difﬁcult to automate what hospitals do reﬂects the almost crippling complexity of what hospitals do and, indeed, what they are. Healthcare is the most complex thing our economy produces; there is more variability and uncertainty at the point of care in an emergency room, intensive care unit, or hospital operating suite than in just about any other part of our economy. However, the fundamental reason why enterprise computing has been so difﬁcult to implement in hospitals is that many of them are not really enterprises. They look like enterprises, with buildings, budgets, and or- ganizational charts, but they function more like loose collections of professions uncomfortably housed in the same physical structures. A coral reef is such a structure, much more a colorful Darwinian ecology than a sentient being. The nervous sys- tem for a jellyﬁsh is going to look and function differently than the nervous system for a higher, thinking organism. Hospitals are like large amoeboid organisms with poorly developed central nervous systems. One can design a nervous system for a collaborative enterprise, but one should not be surprised if it does not work very well if the actors in the enterprise really do not effectively collaborate. Hospitals 53 In addition to the physiology of the organism, there is a work- force problem. Until very recently, health executive and professional education ignored information technology. Vendors as well as providers struggle to ﬁnd qualiﬁed workers at every skill level. Clinical Quality and Decision Support The previous chapter describes the promise of the intelligent clinical information system, undergirded by clinical decision support and care guidelines. The increasing intelligence of clinical information systems has the potential for markedly reducing medical errors. Rules engines built into clinical software will examine the orders themselves to ensure that they are what the physician or nurse intended, compare them to what is known about the patient’s present condition, and provide a “reality” check on care decisions automatically. The central challenge these new clinical tools pose to hospital managements is that they fundamentally challenge the fragmenta- tion of the hospital experience—and an operating culture that places 54 Digital Medicine the needs of hospital departments and professions above the needs of the patient. Computer systems could help alleviate, but are not going to eliminate, professional burnout, poor morale, rivalries among professional groups, continuity problems between clinical departments (“it’s not my department; she’s not my patient”), and the potential for “dropped batons” in a complex hospitalization.
I would like to acknowledge the hard work of the Public Health Medicine Communicable Disease Sub-Group in producing this document viagra extra dosage 150mg without prescription impotence quoad hoc. I am confdent that it will be of great assistance to school personnel as they continue to play their role in controlling infectious diseases purchase line viagra extra dosage erectile dysfunction caverject injection. From time to time cheap 120 mg viagra extra dosage amex erectile dysfunction workup aafp, there will be additions and links to other resources that relate to the management of infectious diseases in schools generic 120 mg viagra extra dosage free shipping erectile dysfunction and zantac. Introduction These guidelines were designed to assist schools to prevent or minimise the spread of infection, illness and disease to staff, pupils and others (such as student teachers and volunteers). They were primarily developed for use by teachers in primary and secondary schools. They aim to raise awareness about common and important infectious diseases and provide guidance on the prevention and management of infectious diseases in educational settings. The guidelines are based on best available evidence and consensus recommendations. Additional advice and support about specifc infectious diseases can be obtained from Local Departments of Public Health The document provides advice on the prevention and control of the most common and important infections encountered in schools. The prevention of transmission of infectious diseases in schools is most likely to be successful if the following are implemented: 1. Schools are ideal places for the spread of infectious diseases because of the large numbers of young people of different ages in close contact with each other some of whom may not have developed good personal habits or immunity to various diseases. Understanding the way different infectious diseases spread allows the correct preventive measures to be applied. Micro-organisms, also known as germs, are tiny living organisms that cannot be seen by the naked eye. Germs can be found in many different places, some live in the environment, some in animals and others in humans. These germs fulfl many important functions and their presence in the human body is necessary for health. Infection develops when germs which do not usually inhabit the human body gain access, multiply and invade human tissue resulting in signs and symptoms of infection (e. Several types of germs cause infection including; bacteria, viruses, fungi, protozoa and parasites. Fungal infections include ringworm and athlete’s foot and parasites include head lice and scabies. Ear infections are caused by germs that are not usually passed from person to person. Chicken pox on the other hand rapidly spreads from person to person and is an example of a highly contagious infectious disease. Once a person comes in contact with an infectious agent or germ, a number of factors infuence whether or not that person becomes ill. These include; the germ itself, the number of germs required to cause infection (i. Other factors depend on us; how strong is our immune system, have we met that germ before, are we resistant to it? Some infections result in lifelong immunity which is why most of us will only develop chicken pox or measles once in our lives, while other infections like the common cold can be caught again and again. Through direct contact, (skin contact, contact with saliva and other body fuids, sexual contact), e. The interval between contact with infection and the time symptoms develop is called the incubation period. For example children with measles are infectious for about 3 days before the appearance of a rash. Spread through the gastrointestinal tract or gut Some diseases are caused by germs which live and multiply in the intestines or gut and are passed out of the body in the faeces. For disease to spread, faeces containing these germs must be carried to the mouth and swallowed. Disease can spread when even very small amounts of faeces, amounts so small that they cannot be seen by the naked eye, contaminate hands or objects and are unknowingly brought to the mouth and swallowed. This is also known as the faecal-oral (faeces to mouth) route of transmission and usually occurs when hands are contaminated after using the toilet. Hands can also contaminate objects such as pencils and door-handles which are then handled, allowing the germs to pass to the next pair of hands and ultimately to the mouth of the next person, and so the infectious chain continues. Gastrointestinal spread is responsible for the spread of most infectious diarrhoea as well as some more generalised infections such as hepatitis A. Spread through the respiratory tract Some infectious diseases are spread by germs that can live and multiply in the eyes, airways (including the nose and mouth), and the lungs. These germs are easily passed from our nose or mouth to our hands and from there to other objects. Some infections are spread by droplets that are expelled by an infected person when they sneeze, cough or talk. Droplet spread usually requires the infected person and the susceptible contact to be relatively close to one another, within about 3 feet. Examples include; common cold, infuenza, meningococcal disease, mumps, rubella and pertussis (whooping cough). Other infections are spread by small aerosol droplets that remain in the air where they are carried on air currents (airborne spread) for some time after they are expelled e. Direct contact A number of infections and infestations (an infestation is when a person is infected with a parasite e. Some infections require only superfcial contact with an infected site for infection to spread e. With others, infection is only passed if there is either direct contact with the infected site or with contaminated objects. All of these infections, as well as many others can also be transmitted by sexual contact. This usually requires a breach in the skin or mucous membranes (the mucous membranes are the delicate linings of the body orifces; the nose, mouth, rectum and vagina). Intact skin provides an effective barrier to these germs and infection following contact with intact skin is extremely unlikely. However, infection can occur if the skin is broken, if someone has open cuts, or if the infected blood is carried through the skin e. It is also possible for infection to occur through sexual intercourse with an infected person. Infection can also be passed from mother-to-infant during pregnancy or at the time of delivery. The potentially serious consequence of acquiring these diseases means that all blood and body fuids must be treated as potentially infectious.