This population represents 30 percent of all adults order cheap vytorin online cholesteryl ester, with a 1 “Thinking Outside The Pillbox: A System-wide Approach to Improving Patient Adherence for Chronic Disease cheap generic vytorin uk cholesterol levels 70 year old. The National Report Card on Adherence is based on an average of answers to questions on nine non-adherent behaviors order vytorin no prescription cholesterol ratio risk. Whether or not, in the past 12 months, patients: • Failed to fill or refill a prescription; • Missed a dose; • Took a lower or higher dose than prescribed; • Stopped a prescription early; • Took an old medication for a new problem without consulting a doctor; • Took someone else’s medicine; or • Forgot whether they’d taken a medication. National Medication Adherence Report Card Average Grade: C+ A B 24% 24% F 15% C 20% D 16% 3 The score can range from 0 (non-adherence on all nine behaviors) to 100 (perfect adherence). Grouping adherence levels [see chart on previous page], just 24 percent earn an A grade for being completely adherent. An additional 24 percent are largely adherent, reporting one non-adherent behavior out of nine (a grade of B). Twenty percent earn a grade of C and 16 percent a D for being somewhat non-adherent, with two or three such behaviors in the past year, respectively. The remaining 15 percent—one in seven adults with chronic conditions—are largely non-adherent, with four or more such behaviors, an F grade. Survey results on a subject such as medication adherence can be influenced by potential reluctance among some respondents to admit to undesirable behaviors. Thus the grades in this survey, if anything, may understate non- adherence—underscoring cause for concern about the extent to which patients are following their medication instructions. In addition to self-reported adherence, the survey assessed demographic, attitudinal and behavioral factors related to prescription drug compliance, including individuals’ health and medical status; their ability to afford prescription medication; their feelings that their prescribed medications are safe, effective and easy to take; where they get their medications; and how informed they feel about their health, among other factors. Regression modeling, a statistical technique that assesses the independent strength of the relationship between two variables while holding other factors constant, identified the six key predictors of medication adherence. Those include—in order of magnitude: • Patients’ personal connection with a pharmacist or pharmacy staff; • How easy it is for them to afford their medications; • The level of continuity they have in their health care; • How important patients feel it is to take their medication exactly as prescribed; • How well informed they feel about their health; and • The extent to which their medication causes unpleasant side effects. These predictors, as well as other results of this survey, indicate a variety of avenues by which health care providers and pharmacists alike can address non-adherence—among them, better informing patients of the importance of adherence, strengthening a sense of personal connection and communication between patients/ caregivers and their health care and pharmacy providers and encouraging patients to discuss side effects with those providers. The survey also found demographic as well as attitudinal and informational differences in adherence: older Americans indicate greater adherence than younger respondents, for example, and those with lung problems report lower adherence than those without this chronic condition. When non-adherent respondents are asked their reasons for failing to comply with doctors’ orders, the most commonly mentioned reason is simply forgetting, cited by more than four in 10 as being a major reason. Other top reasons include running out of medication, being away from home, trying to save money and experiencing side effects. These, as well as further details about the drivers of medication adherence, are outlined in the full report. The survey was produced and analyzed, and this report written, by Langer Research Associates, of New York, N. The full report, including its appendices on methodology, statistical analyses and the full questionnaire and topline results, is available for download at www. Millions of adults age 40 and older with chronic conditions are departing from doctors’ instructions in taking their medications— skipping, missing or forgetting whether they’ve taken doses, failing to fll or refll prescriptions, under- or over-dosing or taking medication prescribed for a different condition or to a different person. An overall C+ grade underscores the problem; the F grades earned by one in seven of these medication users—the equivalent of more than 10 million adults—should heighten alarm. This survey not only establishes the breadth of the problem but evaluates factors that infuence medication non-adherence, suggesting paths to attempt to address the problem. Chief predictors of non-adherence include the presence or absence of a personal connection with a pharmacist or pharmacy staff; the affordability of prescribed medications; a belief in the importance of following instructions in taking medications; patients’ general levels of health information; and the presence of side effects. Pharmacists have a role at the forefront of addressing prescription medication non- Pharmacists have a role at the forefront of addressing prescription medication non-adherence. The results of this survey indicate that much depends on the extent to which pharmacists and pharmacy staff establish a personal connection with their patients and caregivers and engage with them to encourage fuller understanding of the importance of taking medications as prescribed. Independent pharmacists may be particularly well-placed to boost adherence, given their greater personal connection with patients. Health care providers have a vital role to play in stressing the importance of taking medications as prescribed, in monitoring and helping patients avoid or reduce unpleasant side effects that may compromise adherence and in helping to keep patients more generally well-informed about their health conditions. Health care providers, including pharmacists, can help reduce non-adherence by assisting economically vulnerable patients in finding the most affordable medication options. Better information, communication and patient/ caregiver support have been shown in previous studies to increase patients’ engagement and involvement in their health care, their satisfaction with their care and their loyalty to their health care providers. This survey shows yet another potential positive benefit of increased patient engagement—a reduction in the currently high levels of prescription medication non-adherence in the United States, and its associated costs and health risks alike. It is important that you, the patient, take responsibility in knowing which drugs you should try to avoid. Usually any T hearing problem will only be caused by exceeding the recommended dosage of the medications. If you are experiencing a hearing problem, or if there is a hearing disorder in your family, it is imperative that your treating physician and pharmacist be aware of this fact. If you are prescribed one of the medications found on this list, you should speak to your physician to see if another, potentially less toxic drug, could be used in its place. If the drug is over-the-counter, you should ask the pharmacist for a recommendation of a less toxic drug. In the lists that follow, the generic name of the drug is given first, with the trade name, if available, followed in parentheses and capitalized. The inclusion of a particular trade name and the exclusion of another should not be interpreted as prejudicial either for one nor against the other. When a solution Salicylates of an aminoglycoside antibiotic is used on • aspirin and aspirin- the skin together with an aminoglycoside containing products antibiotic used intravenously, there is a • salicylates and methyl- risk of an increase of the ototoxic effect, salicylates (linaments) especially if the solution is used on a (Toxic effects appear to be dose related wound that is open or raw, or if the and are almost always reversible once patient has underlying kidney damage. Hearing loss caused by this check with your doctor or pharmacist to class of antibiotics is usually permanent. The fact that – amikacin (Amakin) aminoglycosides and vancomycin are often – gentamycin (Garamycin) used together intravenously when treating – kanamycin (Kantrex) life-threatening infections futher exaggerates – neomycin (Found in many over-the- the problem. The League for the Hard of Hearing, founded in 1910, is a private not-for-profit rehabilitation agency for infants, children and adults who are hard of hearing, deaf, and deaf-blind. The mission of the League for the Hard of Hearing is to improve the quality of life for people with all degrees of hearing loss. This is accomplished by providing hearing rehabilitation and human service programs for people who are hard of hearing and deaf, and their families, regardless of age or mode of communication. We strive to empower consumers and professionals to achieve their potential and to provide leadership to, and be the model for, disciplines that relate to hearing rehabilitation. The language has Emergency Conditions: Includes risks associ- been modifed to increase readability for a ated with overdose, withdrawal or other drug larger audience and, in keeping with the goal reactions. The special role of the substance abuse counselor n Antianxiety Medications in encouraging discussion between clients and n Stimulant Medications the prescribing physician is emphasized. The generic name of a medication is the actual name of the Others medication and never changes. A generic Each section includes the following topics for medication may be made by many different the different medication types: manufacturers. Additionally, manufacturers Purpose: Describes typical uses of medica- can make several forms of a single medication tions, including specifc symptoms treated and with only slight variations.
Even if one disregards the public health problems created by the use of opioid pain killers effective vytorin 30 mg cholesterol test lipid profile, these medications still are not a good choice for the treatment of acute pain – regardless of the severity vytorin 30 mg cheap cholesterol fighting foods. But in the majority of situations in which opioid painkillers are used today buy vytorin 20 mg on-line cholesterol levels vs mortality, they are not appropriate. Te standard of care in the practice of medicine today is to provide the best treatment that causes the least harms. When there is a treatment that is proven to be both more efective and safer, it is the treatment of choice. By implementing policy that puts restrictions on opioid prescribing to protect public health, policymakers will also improve the treatment of pain by guiding prescribers to use medications that are more efective. It is also important for the medical and dental communities to address this inadequate and unsafe treatment of pain and change practice standards to guide care that is more appropriate for what our patients need and deserve. Single dose oral naproxen Te Journal of the American Medical Association, and naproxen sodium for acute postoperative pain 310(6), 591–608. Cochrane Database of Systematic Reviews, ibuprofen plus paracetamol (acetaminophen) for acute (1). Although celiac disease primarily affects the small intestine, deleterious effects can occur throughout the entire body. The gluten that is found in wheat, rye, and barley is the offending culprit for celiac disease patients. The preva- lence in the United States is estimated to effect 1% of the population. The following article is designed to help identify medications that may contain gluten. In addition to to the active drug in order to make a particular dosage providing bulk, they may be utilized as lubricants for form. Dextrans sugar molecules Detrates mix of sugars resulting from the controlled enzymatic hydrolysis of starch Dextrins result from the hydrolysis of starch (primarily corn or potato) by heat or hydrochloric acid. It can also be obtained from wheat, rice or tapioca Dextri-maltose A sugar that may be obtained from barley malt Dextrose A sugar that is obtained from corn starch Fructose A sugar also known as levulose or fruit sugar Gelatin Obtained from the skin, white connective and bones of animals (by boiling skin, tendons, ligaments, bones, etc with water) Glycerin Historically, glycerin (also known as glycerol), was made the following ways: • Saponification (a type of chemical process) of fats and oils in the manufacturing of soaps • Hydrolysis of fats and oils through pressure and superheated steam • Fermentation of beet sugar molasses in the presence of large amounts of sodium sulfite • Today it is made mostly from propylene (a petroleum product) Glycerols obtained from fats and oils as byproducts in the manufacture of soaps and fatty acids (may also be listed as mono-glycerides or di-glycerides) Glycols products of ethylene oxide gas Iron oxide (rust) used as a coloring agent Kaolin A clay-like substance Lactilol Lactose derivative Lactose Lactose, or milk sugar, is used in the pharmaceutical industry as a filler or binder for the manufacture of coated pills and tablets Maltodextrin A starch hydolysate that is usually obtained from corn but can also be extracted from wheat, potato or rice Mannitol derived from monosaccharides (glucose and mannose) Polysorbates chemically altered sorbitol (a sugar) Povidone synthetic polymers (crospovidone) Pregelatinized starch A starch that has been chemically or mechanically processed. If starch by itself is listed, a call to the manufac- majority of the manufacturers do not provide that infor- turer is the only way to confirm the source of the mation on either the package or the package insert. While they maintain strict reg- There are also the four “Dex-ingredients” derived ulations for the active ingredient of the drug product, from starch (dextrans, dextrose, dextrates, dextrins). This is impor- from any starch source so a call to the manufacturer is tant to understand, especially in the manufacturing of the only way to know if it contains gluten. It is impor- generic drug products, since generic product does not tant to know that other ingredients are derived from have to contain the same excipients as the brand name wheat, but are not hazardous because of the process in product. The generic drug manufacturers must demon- which they are made; conversely, just because a product strate certain absorption characteristics when they is processed does not mean all gluten has been removed. On the Where can a consumer or health care professional other hand, a product may originally start without obtain the necessary drug information? Can this infor- glutens, but in the manufacturing process, may become mation be trusted? This is exactly the reason that a fessional needs to consider two questions when an pharmacist should call the manufacturer as the second inquiry is made about the gluten content of a drug. The step even after reviewing the inactive ingredients in the first question is what are the inactive ingredients or package insert. It is the same case with med- second question that should be asked is, what is the ications. Again, the package insert tion, which includes knowing if excipients contain provides the pharmacist with the starting point. Patients are referred to pharmacists for that the first key words to look for in the inactive ingredi- information just like they are referred to dietitians to get ents section is starch. Gluten Free Pharmaceuticals Resources* One of the most common problems encountered Glutenfree Drugs http://www. The con- Pharmacists may often be called upon to determine sumer should always try to find a source for these products in anticipation of need. Cross contamination during manufactur- ley and rye are not used in the preparation of medica- ing can also occur. Gluten can be found as a normal component of a drug prod- Advil Cold and Sinus uct. When a product contains the word “starch” the source Alavert (all forms) should be identified. While all product formulations should be checked with the Aspirin Enteric Coated 325mg (Leiner,code #44/227, Watson) manufacturer, it is not always possible to do so in a timely Aspirin 81mg chewable (Watson) manner. The likelihood of gluten contamination is small for products Bugs Bunny Chewables that do not contain excipients derived from starch. The product package insert is a good place to start in Chlortrimeton 4 mg tabs search for gluten in medications, but may not completely Chlortrimeton 8mg and 12 mg extend tabs answer the question. Comtrex (tabs/caplets/liquid) Comtrex Deep Chest Cold Comtrex Non Drowsy Freeda’s Vitamins time constraints pharmacists are under; allowing them Ibuprofen (manufact. Lack of Mucinex (all forms) understanding of what gluten is and how gluten can fil- Nature Made brand multivitamins ter into our lives is a barrier to retrieving this informa- Natures Plus Animal Parade tion. Proper education of the health care professional Pepto Bismol Robitussin Cold & Congestion Caplet can be a valuable tool in combating this problem. National Institutes of Health Consensus Development Robitussin Multi Symptom Cold & Flu Caplets Conference Statement. Prevalence of celiac dis- ease in at-risk and not-at-risk groups in the United States: a large Sesame Street Complete Vitamins & Minerals multicenter study. Obesity-related conditions, which include type 2 diabetes, heart disease, stroke and certain cancer types,1 are the leading cause of death among adults in the United States. The decision by the American Medical Association to recognize obesity as a disease in June 2013 created discussion and dialogue on the importance of managing diabetes and supporting provider reimbursement for oversight. If medications are elected as part of the treatment strategy, which already includes lifestyle changes such as increased physical activity and healthy eating patterns, experts recommend a weight loss of 5-10% is needed within the first six months of maximal medication dose to reduce the complications and health risks associated with obesity. Patients who are not achieving the recommended minimum 5% weight loss after three months or who are experiencing adverse effects should be switched to an alternative medication or evaluated for bariatric surgery. Therefore, it is important for diabetes educators to be familiar with the available weight loss medications along with their mechanism of actions, dosages, adverse effects, contraindications and special considerations. A diabetes educator who is familiar with these medications can be an advocate for the patient and make suggestions for potential weight loss medications to the health care team when appropriate. It is important to note that weight loss medications may be particularly beneficial for weight loss maintenance in those patients who lose weight via intensive lifestyle strategies. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Consensus Statement By The American Association Of Clinical Endocrinologists And American College Of Endocrinology On The Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary.
Precautions: Monkeys should be continuously monitored for early signs of significant hypotension and/or bradycardia buy 20mg vytorin amex cholesterol numbers ratio calculator. Treatment may include increasing the rate of intravenous fluid buy generic vytorin 20mg cholesterol biochemistry definition, elevation of lower extremities vytorin 30mg on line xymogen cholesterol, use of pressor agents, or administration of atropine. Attention should be paid to minimize pain on administration of Diprivan Injection. Transient local pain can be minimized if the larger veins of the forearm or leg (e. With lidocaine pretreatment, pain is minimal (incidence less than 10%) and well tolerated. In two well‐ controlled clinical studies using dedicated intravenous catheters, no instances of venous sequelae were observed up to 14 days following induction. Accidental intra‐ arterial injection has been reported in human patients, and, other than pain, there were no major sequelae. Intentional injection into subcutaneous or perivascular tissues of animals caused minimal tissue reaction. During the post‐marketing period, there have been rare reports of local pain, swelling, blisters, and/or tissue necrosis following accidental extravasation of Diprivan Injection. Perioperative myoclonia, rarely including convulsions and opisthotonos, has occurred in temporal relationship in cases in which Diprivan Injection has been administered. Clinical features of anaphylaxis, which may include angioedema, bronchospasm, erythema and hypotension, occur rarely following Diprivan Injection administration, although use of other drugs in most instances makes the relationship to Diprivan Injection unclear. There have been rare reports of pulmonary edema in temporal relationship to the administration of Diprivan Injection, although a causal relationship is unknown. Reports of bradycardia, asystole, and rarely, cardiac arrest have been associated with Diprivan Injection. Drug Interactions: The induction dose requirements of Diprivan Injection may be reduced in patients with intramuscular or intravenous premedication, particularly with narcotics (e. These agents may increase the anesthetic or sedative effects of Diprivan Injection and may also result in more pronounced decreases in systolic, diastolic, and mean arterial pressures and cardiac output. Diprivan Injection does not cause a clinically significant change in onset, intensity or duration of action of the commonly used neuromuscular blocking agents (e. No significant adverse interactions with commonly used premedications or drugs used during anesthesia or sedation (including a range of muscle relaxants, inhalational agents, analgesic agents, and local anesthetic agents) have been observed. If overdosage occurs, Diprivan Injection administration should be discontinued immediately. A minimum period of 5 minutes between adjustments should be allowed for onset of peak drug effect. In diluted form it has been shown to be more stable when in contact with glass than with plastic (95% potency after 2 hours of running infusion in plastic). Administration With Other Fluids: Compatibility of Diprivan Injection with the coadministration of blood/serum/plasma has not been established. Diprivan Injection has been shown to be compatible when administered with the following intravenous fluids. Propofol undergoes oxidative degradation, in the presence of oxygen, and is therefore packaged under nitrogen to eliminate this degradation path. Diprivan Injection is a sterile emulsion containing 10 mg/mL of propofol suitable for intravenous administration. In addition to the active component, propofol, the formulation also contains soybean oil (100 mg/mL), glycerol (22. Xylazine Description: Xylazine is a non‐narcotic compound acting as sedative and analgesic as well as a muscle relaxant. Usage: We mainly use it in combination with Ketamine for minor procedures, which however require the avoidance of unwanted animal‐movements. The combination of ketamine and xylazine provides effect anesthesia for moderate duration procedures. Conduction block can be demonstrated in squid giant axons from which the axoplasm has been removed. Local anesthetics block conduction by decreasing or preventing the large transient increase in the permeability of excitable membranes to Na+ that normally is produced by a slight depolarization of the membrane. This action of local anesthetics is due to their direct interaction with voltage‐gated Na+ channels. As the anesthetic action progressively develops in a nerve, the threshold for electrical excitability gradually increases, the rate of rise of the action potential declines, impulse conduction slows, and the safety factor for conduction decreases; these factors decrease the probability of propagation of the action potential, and nerve conduction fails. In addition to Na+ channels, local anesthetics also can bind to other membrane proteins. However, since the interaction of local anesthetics with K+ channels requires higher concentrations of drug, blockade of conduction is not accompanied by any large or consistent change in resting membrane potential due to block of K+ channels. Quaternary analogs of local anesthetics block conduction when applied internally to perfused giant axons of squid, but they are relatively ineffective when applied externally. These observations suggest that the site at which local anesthetics act, at least in their charged form, is accessible only from the inner surface of the membrane. Therefore, local anesthetics applied externally first must cross the membrane before they can exert a blocking action. Although a variety of physicochemical models have been proposed to explain how local anesthetics achieve conduction block, it is now generally accepted that the major mechanism of action of these drugs involves their interaction with one or more specific binding sites within the Na+ channel. Lidocaine Lidocaine is used to produce local anesthesia following subcutaneous injection. It is readily absorbed following parenteral administration and thus does not long remain at the site of injection. Muscle Relaxants Vecuronium bromide Description: Norcuron (vecuronium bromide) for injection is a nondepolarizing neuromuscular blocking agent of intermediate duration. Norcuron is supplied as a sterile nonpyrogenic freeze‐dried buffered cake of very fine microscopic crystalline particles for intravenous injection only. The antagonism to acetylcholine is inhibited and neuromuscular block is reversed by acetylcholinesterase inhibitors such as neostigmine, edrophonium, and pyridostigmine. Norcuron is about 1/3 more potent than pancuronium; the duration of neuromuscular blockade produced by Norcuron is shorter than that of pancuronium at initially equipotent doses. The time to onset of paralysis decreases and the duration of maximum effect increases with increasing Norcuron doses. The use of a peripheral nerve stimulator is recommended in assessing the degree of muscular relaxation with all neuromuscular blocking drugs. Under balanced anesthesia, the time to recovery to 25% of control (clinical duration) is approximately 25 to 40 minutes after injection and recovery is usually 95% complete approximately 45‐ 65 minutes after injection of intubating dose. The neuromuscular blocking action of Norcuron is slightly enhanced in the presence of potent inhalation anesthetics.
A randomized trial of immediate vitrectomy and of intravenous antibiotics for the Baillif S buy cheapest vytorin cholesterol ratio for life insurance, Roure-Sobas C generic vytorin 30mg without prescription cholesterol hdl ratio emedicine, Le-Duff F vytorin 30mg with visa cholesterol levels ketogenic diet, Kodjikian L. Arch contamination during phacoemulsifcation in a university teaching Ophthalmol 1995; 113: 1479-1496 hospital. A comparison of eyelid and intraocular isolates using pulsed- postoperative endophthalmitis after cataract surgery. Arch Ophthalmol 1997;115:357–61 Refract Surg 2009; 35: 1523-31 Barry P, Behrens-Baumann W, Pleyer U, Seal D, 2007 2nd Edition 12. J Cataract Refract diagnostic techniques in postoperative endophthalmitis in the Surg, in press. Endophthalmitis prophylaxis in cataract surgery: Overview of current practice patterns in 9 European countries. 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