If at any time you feel you are exercising beyond your current fitness abilities, or feel discomfort, discontinue exercise immediately and reconsider your participation in this program. The golf warm-up stretching program provided in this publication should not be attempted by anyone who does not meet minimum fitness requirements, or who has a history of hip, knee, ankle, shoulder, elbow, wrist or spinal (neck or back) problems. There are many other fitness alternatives if you have weaknesses or are prone to injuries. This onsite diagnostic capability eliminates the need of added appointments and delayed diagnosis and treatment. Each issue contains information to help you stay healthy and live an active life with tips on injury prevention, nutrition, sports conditioning, research and newsmakers. Editor & Designer Larana Stropus Editor & Contributor Photographer Keith Tesch Editor & Contributor. Full recovery (patients with no symptoms) at all time points was more common in the betamethasone group. Steroids Introduction Chronic tendinopathy of the lateral epicondyle of the humerus, commonly called tennis elbow, is one of the most frequent tendinopathies caused by recurrent overload of the muscle origins [1]. The use of this preparation is particularly important as a treatment option in soft tissue disorders where the healing response has failed and the resulting inflammation has caused a chronic condition. An autologous preparation injected into the area of the tendinopathy initiates a healing response [16, 17]. Patients who failed to attend one of the followup visits, refused to participate in study or had pervious operative procedures of the elbow were excluded. Sixty-four patients who met the inclusion criteria were included in the first group and 56 in the second. Two days after the injection, patients were asked whether or not they felt any pain. In the case of small counts in some fields of the table, the Yates correction was used. Before making comparisons of means, the normality of the distributions of the measurable traits were examined by the Kolmogorov compliance test. Because the distributions of the characteristics analysed in the study in each group were markedly not normal, nonparametric tests were used to compare means: the Mann Whitney test was used to compare two independent groups and the Friedman test was used to compare a number of dependent groups. As statistically significant changes were identified in the tests using point scores, the Wilcoxon pair test was then used as a posthoc test. To test dependence between parameters, the r linear correlation coefficient was used. In each tested group, at each stage of the study, a test was made of the dependence between age and the achieved point score. To assess the effect of age on the point score, a coefficient of determination was designated, which was the square of the correlation coefficient. Discussion A number of studies make direct comparisons between the results of using a platelet-rich plasma preparation and steroid preparations to treat tendinopathy of the lateral epicondyle of the humerus [68, 10, 19]. The therapeutic effect was found to be slower than that of betamethazone: the number of scores higher than 50 points at the start of treatment was 24, 11 after six weeks, zero after six months, and at the end of the observation period, the number insignificantly rose to 2 Table 3. In the group of patients treated with betamethazone, 36 (78 %) very good results were noted by the end of the observation period. On the day the preparation was given, the number of scores above 50 points was 30, which sharply fell to six at six weeks of treatment, with only three such scores being recorded at six months. In addition, a quicker therapeutic effect was noted for steroid injections compared to platelet-rich plasma, although the effect was not as long lasting. These same group evaluated the same group of patients for two years from the administration of injections, achieving better results in the group treated with platelet-rich plasma preparations when returning to baseline than patients treated with steroids [7]. A similar conclusion regarding the short-term beneficial effects of steroid therapy may be found in Coombes et al. The most recent report comparing platelet-rich plasma, steroid and saline solution therapies is that of Krogh et al. The authors compare three groups of 20 patients, treated with the three preparations for a period of three months. The authors did not find any advantage to therapy using platelet-rich plasma or steroids over the control group administered with physiological saline during the final observation period. However, they discuss the fast reduction of painful symptoms in the group treated with steroids. No statistically significant difference in Liverpool Elbow Score was observed, and on the basis of the obtained results they conclude that plateletrich plasma is as effective as a form of analgesic therapy.
Note that multiple victims, as suggested earlier, are a sufficient but not a necessary condition for diagnosis; the criteria may also be met if the individual acknowledges intense voyeuristic sexual interest. The Criterion A time frame, indicating that signs or symptoms of voyeurism must have persisted for at least 6 months, should also be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in secretly watching unsuspecting naked or sexually active others is not merely transient. To alleviate the risk of pathologizing normative sexual interest and behavior during pubertal adoles cence, the minimum age for the diagnosis of voyeuristic disorder is 18 years (Criterion C). Prevalence Voyeuristic acts are the most common of potentially law-breaking sexual behaviors. However, based on voyeuris tic sexual acts in nonclinical samples, the highest possible lifetime prevalence for voyeuris tic disorder is approximately 12% in males and 4% in females. Development and Course Adult males with voyeuristic disorder often first become aware of their sexual interest in secretly watching unsuspecting persons during adolescence. However, the minimum age for a diagnosis of voyeuristic disorder is 18 years because there is substantial difficulty in differentiating it from age-appropriate puberty-related sexual curiosity and activity. Voyeuristic disorder, however, per defini tion requires one or more contributing factors that may change over time with or without treatment: subjective distress (e. Voyeurism is a necessary precondition for voyeuristic disorder; hence, risk factors for voyeurism should also increase the rate of voyeuristic disorder. Childhood sexual abuse, substance misuse, and sexual preoccupation/ hypersexuality have been suggested as risk factors, although the causal relationship to voyeurism is uncertain and the specificity unclear. Gender-Related Diagnostic Issues Voyeuristic disorder is very uncommon among females in clinical settings, while the maleto-female ratio for single sexually arousing voyeuristic acts might be 3:1. Conduct disorder in adolescents and antisocial personality disorder would be characterized by additional norm-breaking and antisocial behaviors, and the specific sexual interest in secretly watching unsuspect ing others who are naked or engaging in sexual activity should be lacking. Substance use disorders might involve single voyeuristic ep isodes by intoxicated individuals but should not involve the typical sexual interest in se cretly watching unsuspecting persons being naked or engaging in sexual activity. Hence, recurrent voyeuristic sexual fantasies, urges, or behaviors that occur also when the indi vidual is not intoxicated suggest that voyeuristic disorder might be present. Comorbidity Known comorbidities in voyeuristic disorder are largely based on research with males suspected of or convicted for acts involving the secret watching of unsuspecting nude or sexually active persons. Hence, these comorbidities might not apply to all individuals with voyeuristic disorder. Conditions that occur comorbidly with voyeuristic disorder include hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder. De pressive, bipolar, anxiety, and substance use disorders; attention-deficit/hyperactivity disorder; and conduct disorder and antisocial personality disorder are also frequent comorbid conditions. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Subtypes the subtypes for exhibitionistic disorder are based on the age or physical maturity of the non consenting individuals to whom the individual prefers to expose his or her genitals. This specifier should help draw adequate attention to characteristics of victims of individuals with exhibitionistic disorder to prevent co-occurring pedophilic disorder from being overlooked. However, indi cations that the individual with exhibitionistic disorder is sexually attracted to exposing his or her genitals to children should not preclude a diagnosis of pedophilic disorder. Specifiers the "in full remission" specifier does not address the continued presence or absence of ex hibitionism per se, which may still be present after behaviors and distress have remitted. Diagnostic Features the diagnostic criteria for exhibitionistic disorder can apply both to individuals who more or less freely disclose this paraphilia and to those who categorically deny any sexual attraction to exposing their genitals to unsuspecting persons despite substantial objective evidence to the contrary. If disclosing individuals also report psychosocial difficulties because of their sexual attractions or preferences for exposing, they may be diagnosed with exhibitionistic disorder. In contrast, if they declare no distress (exemplified by absence of anxiety, obsessions, and guilt or shame about these paraphilic impulses) and are not impaired by this sexual interest in other important areas of functioning, and their self-reported, psychiatric, or legal histories indicate that they do not act on them, they could be ascertained as having exhibitionistic sexual interest but not be diagnosed with exhibitionistic disorder. Examples of nondisclosing individuals include those who have exposed themselves repeatedly to unsuspecting persons on separate occasions but who deny any urges or fan tasies about such sexual behavior and who report that known episodes of exposure were all accidental and nonsexual. Others may disclose past episodes of sexual behavior involv ing genital exposure but refute any significant or sustained sexual interest in such behav ior. Since these individuals deny having urges or fantasies involving genital exposure, it follows that they would also deny feeling subjectively distressed or socially impaired by such impulses. Such individuals may be diagnosed with exhibitionistic disorder despite their negative self-report.
These centers are considered as third line referral centers for patients suffering chronic pain refractory to conventional treatment in first and second line care. The multidisciplinary team of pain centers is composed of a pain specialist (mostly anesthesiologist with specialization in chronic pain management), pain nurse, psychologist/psychiatrist, physiotherapist and rehabilitation specialist working together to establish a treatment plan. The coordinators of the 9 centers are working together with the representatives from the health authorities and the health insurers to establish a standardized registration scheme of the patients consulting the centers. The data collection will only start in January 2007 and therefore this information is not available for this study. The databases and information sources described above will be first assessed for their validity and usefulness. The study uses the data relative to the year 2004, which is the most recent and complete registration period. Type and source of information Health care setting Type of intervention Diagnosis Non-surgical treatment Surgical treatment Ambulatory care Community based Intego Soc. Its objective is to develop a database with information about morbidity in the first line care. The Intego database provides information on the incidence and prevalence of diseases in Flanders, but also on their diagnostic procedures and management in family practice. The data are collected via an automated system using the structured information of the electronic medical record. After an evaluation study, the project received support of the authorities because of the need for morbidity data in view of policy decisions. This program uses keywords and codes for diagnosis, prescription of medication, laboratory results, allergies and medical imaging. The keywords are converted into a classification system in the central Intego-database. Data are collected by a group of general practitioners, selected for their quality of registration. The population studied in the Intego project is representative in terms of age and gender distribution for the population of Flanders 329. Definition of the population the knowledge of the source population is a prerequisite for computing epidemiological data and drawing conclusions. By dividing the yearly contact group by this percentage, the practice population can be calculated. Additional standardization to the Flemish population or a standard population is possible. In 2005, the Intego database contained data on approximately 850 000 patient years. The evolution of the Yearly Contact group and the Intego Practice Population in comparison with the Flanders population is illustrated in appendix 2. Data collected in the Intego project the following data are collected in the Intego project: patient sex, and year of birth, the years when the patient consulted, patient medical history, diagnoses, laboratory results, medical imaging (when the results were recorded), and the medication prescribed. The incidences are calculated as the number of new diagnoses per 1000 patient years with the yearly contact group or the practice population as denominator. So it is possible to determine on which date for which patient a specific diagnosis was recorded and a drug prescribed but one can not conclude if the drug was prescribed for that specific diagnosis. For example in the case of a patient with low back pain and headache, it is impossible to know if paracetamol was prescribed for the back pain, for the headache or for both. The use of medication and laboratory investigations as well as the co-morbidity for the patient population suffering low back pain will be compared with the group without low back pain. The 10-years data will be used to define the number of patients with the symptom in the past and the evolution of incidence over a longer period. The proportion of patients diagnosed at least once with low back pain over a 10-years registration period was calculated. The incidence of co-morbidity was compared for the group with and the group without low back pain. It was however impossible to state if the comorbidity was a cause or a consequence or was independent from low back pain. Pharmacological treatment of low backache As described above there is no direct relation in the database between the diagnosis and the prescribed medication. It is impossible to state if a drug was specifically prescribed for the complaint under study within a specific period after the diagnosis.
The facility must indicate the specific locations from which they plan to submit antimicrobial use data in the Patient Safety Monthly Reporting Plan. Refer to Table 1 and Table 2 for the definitions of drug-specific antimicrobial days and stratification based on route of administration. Please note antimicrobials that have an extended half-life, such as Dalbavancin and Oritavancin, are only counted as an antimicrobial day on the day of administration. Similarly, in the case of renal impairment, antimicrobials such as Vancomycin are only counted as an antimicrobial day on the day of administration. If use of non-formulary agents can be accurately electronically captured, no use of those agents in each location/month would be reported as "0" (zero). Data Elements for Antimicrobial Days Data Element Details Antimicrobial Agents Defined as select antimicrobial agents and stratified by route of administration (specifically, intravenous, intramuscular, digestive, and respiratory). The list of select antimicrobials will evolve with time as new agents become commercially available and old agents are removed from the market. Usage derived from other data sources (for example, pharmacy orders, doses dispensed, doses billed) cannot be submitted. Antimicrobial days for a specific antimicrobial agent and stratification by route of administration are aggregated monthly per location. Days present: Days present are defined as the time period during which a given patient is at risk for antimicrobial exposure in a given patient location. Days present is further defined below in context of calculation for patient care location-specific analyses and facility-wide inpatient analyses. Please note that a separate calculation for days present is required for each patient care location compared to facility-wide inpatient. For patient care location-specific analyses, days present are calculated as the number of patients who were present, regardless of patient status (for example, inpatient, observation), for any portion of each day during a calendar month for a patient care location. The aggregate measure is calculated by summing days present for that location and month. The day of admission, discharge, and transfer to and from locations will be included in the days present count. Below are examples that illustrate appropriate days present calculation: · A patient admitted to the medical ward on Monday and discharged two days later on Wednesday contributes three days present in the medical ward because the patient was present in that specific location at some point during each of the three calendar days (specifically, Monday, Tuesday, and Wednesday). One patient can only contribute one day present for a specific location per calendar day. One patient cannot contribute more than one day present to any one unique location on the same day but can contribute a day present to two different locations on the same day. For example, a patient transferred from the surgical ward to the operating room and back to the surgical ward in a calendar day contributes one day present to the surgical ward and one day present to the operating room. The aggregate measure is calculated by summing up all the days present for facility-wide inpatient for a given month. The calculation must be a separate summation for facility-wide inpatient analyses. Admissions: Admissions are defined as the aggregate number of patients admitted to an inpatient location within the facility (facility-wide inpatient) starting on first day of each calendar month through the last day of the calendar month. A patient admitted to an inpatient unit would be counted as an admission even if they were discharged that same calendar day. Location-specific and Facility-wide Inpatient Metrics Patient Care Location-Specific Analyses Rate of Antimicrobial Days per 1,000 Days Present Ч 1000 Notes: · One patient can contribute only one day present per calendar day for each specific location. Thus, one denominator is obtained for all inpatient locations in an entire facility. For example, descriptive analysis reports such as line lists, bar charts and pie charts are available. Separate predictive models are developed for each specific antimicrobial agent category. Rates can also be generated for well baby and step down neonatal nurseries for select antimicrobial groupings.
I s ha t ee b n 5 y s ar e n si ce t he p ic bl u io at n of t s hi C lin ic P al r t ac i ce G ui d e lin e d an i s ti s t ct e bj u o pd u a g tin. In a second phase, a search of systematic reviews, meta-analysis odatabases mentioned above has been carried out. In a third and evaluation reports in the n phase, there has been an expanded search of primary studies (clinical trials, observatio a tional studies, studies on diagnostic and prognostic testing). This update is done e through the incorporation of updated literature searches, particularly focusing on those aspects tic c where the recommendations could be substantially modified. The methodology to carry out this ra P update process is reflected in the Methodological Manual Update for Clinical Practice Guidelines, al available at All societies are represented by one ofup the development group members or external reviewers. The level of severity, type and age of onset of each of l C the criteria will vary from one individual to another, defining each of the diagnostic categories. Aetiology Autism is a complex brain disorder that affects coordination, synchronisation and integration between different brain areas. The essential abnormalities of these disorders (social interactions, repetitive communication and behaviours and restrictive interests) are justified by multiple brain abnormalities, functional and / or structural, which are not always the same50. Recent je advances indicate the importance of genetic factors and some possible environmental factors that b lead to very early brain abnormalities. Of these genes, some act in all cases and others in various lic b combinations that would influence in family variations and in the severity or the expression of the pu proposed is that each of the genes involved provides a small amount phenotype. The hypothesis e of risk for the disorder and that only when that amount exceeds a certain threshold, the person has th 57 the full phenotypee. Other genetic aspects which contribute to autism are quantitative, polygenic 58, nc59. All of these genetic features, as well as increasing comorbidity, explain the and pleiotropic si extensive phenotypic spectrum used to show these disorders. In addition, the balance between s ar unfavourable quantitative traits and protective quantitative traits contributes to understanding the ye great variability among members of the same family for any of the traits of autism. The situation is 5more complicated, taking into account that the expression of quantitative traits, both positive even en eand negative, has a strong environmental influence. Karyotype studies have shown that almost all chromosomes are involved in a 5-9% of people with autism60,74-78. In a person with autism, what is being specifically explored is the presence of "fragile X chromosome. In 5-8% of people with autism, monogenic disorders with specific phenotypeis genotype and t are docui characteristics, associated with a biological disorder that allow their individualisation mented51,52,54,90,91. However, it can be helpful, if there is history or there is a suspicion of epileptic seizures, and / or need to discard or characterise suspicion of specific syndromes. Recent studies indicate that the presence of IgG antibodies in maternal plasma e th during pregnancy against foetal brain proteins, together with genetic lability, may lead to global neurodevelopmental regression and thus may cause the development of early-onset autism122-124. Most obstetric complications are generally a consequence of foetal anomalies acquired in the early stages of embryonic development, rather than the cause of autism, as happens in a high percentage of difficult births of children without autism125. The inconsistency of the theories that say that je been children with autism metabolize incompletely the metabolic products of gluten and milk b has su shown, so it does not justify the use of free gluten and casein diets127. In relation to the theory of the triple-virus vaccine,t it was believed that Hg, which was a preservative, was a causal factor in autism. It is important to highlight that the elimination of thiomersal (ethylmere cury) in vaccines has not provided a decrease in the prevalence of autism. Intra-utero exposure to various toxic agents thatid u may alter neurodevelopment and generate autistic-like foetopathy has been analysed. TheseG include valproic acid and other antiepileptic drugs, cocaine, alcohol, thalidomide (although iit e a drug which has been contrainis c dicated in pregnant women for decades), lead, chronic exposure of the mother and foetus to low ct a levels of carbon monoxide carbon and others, not always obtaining the same conclusions. Comorbidity and syndromic autism th pu ic bl a l I s ha t e nctalking about autism without further specification, it refers to idiopathic or priIn general, when si mary autism without associated syndromes. The additional evidence required are determined by the search for a specific aetiology or 5 associated, resulting in a carrier of a "double syndrome", i.
Common clinical examples are anxiety-exacerbating asthma, denial of need for treatment for acute chest pain, and manip ulation of insulin by an individual v^ith diabetes wishing to lose weight. Many different psychological factors have been demonstrated to adversely influence medical conditions- for example, symptoms of depression or anxiety, stressful life events, relationship style, personality traits, and coping styles. The adverse effects can range from acute, with imme diate medical consequences (e. This diagnosis should be reserved for situations in which the effect of the psychological factor on the medical condition is evident and the psychological factor has clinically sig nificant effects on the course or outcome of the medical condition. Abnormal psychologi cal or behavioral symptoms that develop in response to a medical condition are more properly coded as an adjustment disorder (a clinically significant psychological response to an identifiable stressor). There must be reasonable evidence to suggest an association between the psychological factors and the medical condition, although it may often not be possible to demonstrate direct causality or the mechanisms underlying the relationship. Prevalence the prevalence of psychological factors affecting other medical conditions is unclear. Development and Course Psychological factors affecting other medical conditions can occur across the lifespan. Par ticularly with young children, corroborative history from parents or school can assist the di agnostic evaluation. Culture-Related Diagnostic issues Many differences between cultures may influence psychological factors and their effects on medical conditions, such as those in language and communication style, explanatory models of illness, patterns of seeking health care, service availability and organization, doctor-patient relationships and other healing practices, family and gender roles, and at titudes toward pain and death. Psychological factors affecting other medical conditions must be differentiated from culturally specific behaviors such as using faith or spiritual healers or other variations in illness management that are acceptable within a culture and represent an attempt to help the medical condition rather than interfere with it. These local practices may complement rather than obstruct evidence-based interventions. If they do not adversely affect outcomes, they should not be pathologized as psychological factors affecting other medical conditions. Functional Consequences of Psychological Factors Affecting Other Medical Conditions Psychological and behavioral factors have been demonstrated to affect the course of many medical diseases. A temporal association between symptoms of a mental disorder and those of a medical condition is also characteristic of a mental disorder due to another medical condition, but the presumed causality is in the op posite direction. In a mental disorder due to another medical condition, the medical condition is judged to be causing the mental disorder through a direct physiological mech anism. In psychological factors affecting other medical conditions, the psychological or be havioral factors are judged to affect the course of the medical condition. Abnormal psychological or behavioral symptoms that develop in response to a medical condition are more properly coded as an adjustment disorder (a clin ically significant psychological response to an identifiable stressor). For example, an indi vidual with angina that is precipitated whenever he becomes enraged would be diagnosed as having psychological factors affecting other medical conditions, whereas an individual with angina who developed maladaptive anticipatory anxiety would be diagnosed as hav ing an adjustment disorder with anxiety. In clinical practice, however, psychological fac tors and a medical condition are often mutually exacerbating (e. Other mental disorders frequently result in medical complications, most notably substance use disorders (e. If an individual has a coexisting major mental disorder that adversely affects or causes another medical condition, diagno ses of the mental disorder and the medical condition are usually sufficient. Psychological factors affecting other medical conditions is diagnosed when the psychological traits or behaviors do not meet criteria for a mental diagnosis. Somatic symptom disorder is characterized by a combina tion of distressing somatic symptoms and excessive or maladaptive thoughts, feelings, and behavior in response to these symptoms or associated health concerns. In psychological fac tors affecting other medical conditions, the emphasis is on the exacerbation of the medical condition (e. In somatic symptom disorder, the emphasis is on maladaptive thoughts, feelings, and behavior (e. Illness anxiety disorder is characterized by high illness anxiety that is distressing and/or disruptive to daily life with minimal somatic symptoms. In psychological factors affecting other medical conditions, anx iety may be a relevant psychological factor affecting a medical condition, but the clinical concern is the adverse effects on the medical condition.
Disinfection - risk factors Efficacy of disinfection depends on water quality parameters such as pH and turbidity, which may compromise the disinfection process. Even if enough chemical or other agent could be added to achieve sterilization, the system would rapidly become recolonized with microorganisms, since cooling systems are open to the environment. The most significant practical consequence of attempted sterilization would be selection in biofilms of increasingly tolerant microbial communities comprising the survivors of the applied antimicrobial treatment (Russell, 2000). Biofilms - risk factors Cooling towers and evaporative condensers typically move large quantities of air, and are excellent air scrubbers or washers. Thus, dirt, dust and other particulate matter enter the cooling tower water in the evaporative cooling process, as large amounts of air are moved through the unit. Depending on location, the quantity of such material added to the cooling water can be substantial (e. Organic matter and other debris present in the air can therefore accumulate in the cooling water. This material may serve as a nutrient source for the growth of microorganisms, including legionellae. Diverse biofilms, which can support the growth of legionellae, may be present on all wet or moist surfaces throughout the system; for example, on heat exchangers, the fill, the sump and pipes (Geary, 2000; Donlan, 2002). Temperature - risk factors the typical temperature of the water in a cooling tower ranges from 29 °C to 35 °C at the heat exchanger, and from 22 °C to 28 °C at the cooling tower. These temperature ranges are conducive to the growth of legionellae and their hosts. Design and materials used in construction - risk factors Stagnation of the system or areas of stagnant water (e. Wherever possible, cooling towers should be located well away from building air intakes, other building openings and areas of public access. The influence of adjacent buildings, as well as prevailing wind directions, should be taken into account when locating a cooling tower. Consideration should be given to the effects of reversal of airflow through some towers when the tower fan is idle, and preventive dampers should be installed if necessary. In certain situations, the potential risk of having a tower in a particular site may be so great as to require its relocation; for example, where there are air inlets to hospital wards with high-risk patients. Dry cooling systems are used in some situations, particularly on small (175350 kW) systems. Although such systems use substantially more energy, and are typically larger and noisier than cooling towers, there is no known Legionella risk associated with dry systems. The steps involved in monitoring, some of which are discussed below, are to: · identify control measures (Section 5. This is achieved by minimizing microbial growth, scale, corrosion, and sediment or deposition of solids (organic or inorganic) on heat-transfer surfaces, through implementing the control measures outlined below. Source water quality - control measures Where a holding tank is used to hold make-up water, the tank should be cleaned of rust, sludge and sediment whenever the tower is cleaned and disinfected (which should be done about twice a year). Where surface water from lakes, rivers, streams or reservoirs is used, antimicrobial treatment before the water enters the cooling system provides a practical and highly effective aid to control microbial fouling in the system. Water softening reduces the potential of the system to form biofilms, but may increase corrosion. Reduction of organic load in the source water by chlorination or filtration (or both in concert) helps to remove nutrients that could lead to legionellae proliferation. Chlorination used to reduce the organic load may also serve to disinfect the water of its inherent microbial load. Water treatment and water distribution - control measures A system should be designed in such a way that water circulates through all parts of the system that should be wetted whenever it is operational. Deadlegs on existing systems should be removed or shortened (so that their length is no longer than the diameter of the pipe), or should be modified to permit the circulation of chemically treated water. Dirt, organic matter and other debris should be kept to a minimum, as water treatment chemicals are generally more effective when the system is kept clean. After stagnation of part or all of the system, system operation should always be coordinated with full chemical treatment of the water.
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