Incoherent Qubit Control Using the Quantum Zeno Effect.

The quantum Zeno effect is the suppression of Hamiltonian evolution by repeated observation, which pins the system to an eigenstate of the measurement observable. Using measurement alone, control of the state can be achieved if the observable is slowly varied, so that the state tracks the now time-dependent eigenstate. We demonstrate this using a circuit-QED readout technique that couples to a dynamically controllable observable of a qubit. Continuous monitoring of the measurement record allows us to detect an escape from the eigenstate, thus serving as a built-in form of error detection. We show this by postselecting on realizations with high fidelity with respect to the target state. Our dynamical measurement operator technique offers a new tool for numerous forms of quantum feedback protocols, including adaptive measurements and rapid state purification.

Stroboscopic Qubit Measurement with Squeezed Illumination.

Microwave squeezing represents the ultimate sensitivity frontier for superconducting qubit measurement. However, measurement enhancement has remained elusive, in part because integration with standard dispersive readout pollutes the signal channel with antisqueezed noise. Here we induce a stroboscopic light-matter coupling with superior squeezing compatibility, and observe an increase in the final signal-to-noise ratio of 24%. Squeezing the orthogonal phase slows measurement-induced dephasing by a factor of 1.8. This scheme provides a means to the practical application of squeezing for qubit measurement.

Approach in glucocorticoid-induced osteoporosis prevention: results from the Italian multicenter observational EGEO study.

Glucocorticoid-induced osteoporosis (GIO) is the most frequent cause of secondary osteoporosis. GIO is linked to glucocorticoids (GC) daily assumption with maximum effect within first months of treatment and decreasing to basal levels as the therapy is discontinued. In Italy, primary prevention of GIO is suggested when GC therapy (prednisone >5 mg/day or equivalent) is taken for longer than 3 months. Lazio GISMO (Italian Group for Study and Diagnosis of Bone Metabolism Diseases) group organized the GC and Osteoporosis Epidemiology study (EGEO) to evaluate physician's approach in preventing GIO. The study involved 19 osteoporosis centers. Patients taking long-term GC therapy were recruited and information collected: medical history and anthropometric data, GC therapy, primary disease, physician's specialty, osteopororosis screening, and pharmacological intervention. The study included 1334 patients. Mean age was 63 ± 13 yr; 243 (18%) patients had a history of falls from standing position in the previous 12 months, 78 (35%) vertebral fractures, 91 (41%) fractures other than vertebral, 27 (12%) femoral fractures, and 27 (12%) multiple sites fractures. The molecules of GC more often prescribed were prednisone and 6-metil prednisolone. One thousand and forty patients (78%) were taking GC for more than 6 months. GC therapy was prescribed more frequently by rheumatologists (62%). Antiosteoporotic drugs for GIO prevention were prescribed in 431 patients (32%). Among the patients, only 27% (360) received calcium and vitamin D supplements, and 39% (319) treated by rheumatologists received anti-resorptive drugs. In conclusion, our data show that in Italy, as already described elsewhere, only a small subpopulation of GC-treated patients was supported by an anti-osteoporotic therapy, indicating the need to further stimulate awareness of both patients and specialists, prescribing GC therapy, to an appropriate and prompt GIO prevention.

A new chance to maintain remission induced by anti-TNF agents in rheumatoid arthritis patients: CYnAR study II of a 12-month follow-up.

The advent of biological therapies represented the beginning of a new era in the therapy of Rheumatoid Arthritis (RA), as demonstrated in several studies, but still many questions about their safety, especially in long term use, and correct administration time remain unanswered. Once remission is achieved, the orientation of clinicians regarding the maintenance of biological therapy or the switch to another immunosuppressive therapy is still uncertain. In our previous study 21 patients affected by RA who reached remission by the use of a combined therapy of anti-TNF drugs and methotrexate (MTX) underwent CyA-MTX combination therapy for maintaining remission state and were evaluated during a 6-month follow-up. The present study aims to investigate these data by a longer follow-up (12 months) and on a larger population. Fifty-three RA patients, with a disease duration of less than 3 years and DAS28<3.2 that reached a level of low disease activity within 6-8 months from the beginning of anti-TNF and methotrexate therapy, were enrolled in the study. By the suspension of anti-TNF therapy, patients underwent A-Cyclosporine (2-3 mg/kg/day) and methotrexate (15mg/week) therapy. DAS28, Pain VAS, Erythrosedimentation rate (ESR), C Reactive Protein (CRP) were all tested at time 0 and every 2 months after the interruption of the anti-TNF therapy and the beginning of A-Cyclosporine and methotrexate therapy, as well as liver and kidney profiles. Side effects were also recorded. Of 53 patients, 50 completed the study with a 12-month follow-up. Twenty-one (42%) patients maintained clinical parameters within low disease activity values at 12 months, while 29 (58%) patients showed an increase in DAS28 and other parameters: 16 (32%) patients at the 6-month control, 13 (26%) patients at the 12-month control. Our data show that 42% of the patients undergoing A-Cyclosporin and Methotrexate therapy maintained low disease activity parameters of rheumatoid arthritis, obtained after 6-8 months of anti-TNF therapy. Further studies on larger populations are necessary in order to confirm such results and identify predictor factors for different responses.

A Pilot Study to Detect Agitation in People Living with Dementia Using Multi-Modal Sensors.

People living with dementia (PLwD) often exhibit behavioral and psychological symptoms, such as episodes of agitation and aggression. Agitated behavior in PLwD causes distress and increases the risk of injury to both patients and caregivers. In this paper, we present the use of a multi-modal wearable device that captures motion and physiological indicators to detect agitation in PLwD. We identify features extracted from sensor signals that are the most relevant for agitation detection. We hypothesize that combining multi-modal sensor data will be more effective to identify agitation in PLwD in comparison to a single sensor. The results of this unique pilot study are based on 17 participants' data collected during 600 days from PLwD admitted to a Specialized Dementia Unit. Our findings show the importance of using multi-modal sensor data and highlight the most significant features for agitation detection.

Can Cyclosporine-A associated to methotrexate maintain remission induced by anti-TNF agents in rheumatoid arthritis patients? (Cynar pilot study).

Biological therapies, such as etanercept, adalimumab and infliximab, have demonstrated good efficacy in inducing rheumatoid arthritis to low disease activity levels. Nevertheless, their cost, as well as the related risk of side effects, especially in long-term therapies, are still high. Furthermore, there is a good deal of evidence proving loss of efficacy of such therapies in the long term, often necessitating the shift from one specific anti-TNF biological treatment to another. There are also other open debates on the amount of time a patient should undergo an anti-TNF therapy, on the possibility of inducing a complete remission in early arthritis and, once remission or low disease activity is obtained, on the possibility of interrupting the anti-TNF-based therapy. In this study we investigated whether A-Cyclosporin and Methotrexate association may be effective in maintaining low disease activity obtained by anti-TNF therapies. Twenty-three rheumatoid arthritis-affected patients, whose diagnosis was made according to ACR criteria, with a disease duration of less than 3 years, and DAS28<3.2 that reached a level of low disease activity within 6-8 months from beginning anti-TNF and Methotrexate therapy, were enrolled in the study. After the suspension of anti-TNF therapy, patients were started on A-Cyclosporine (2-3 mg/kg/day) and Methotrexate (15mg/week) therapy. DAS28, Pain VAS, Erythrosedimentation Rate (ESR), and C Reactive Protein (CRP) were all tested at time 0 and at 6 months, as well as liver and kidney profiles, after the interruption of the anti-TNF therapy and the beginning of A-Cyclosporine and Methotrexate therapy. Side effects were also recorded. Of 23 patients undergoing the A-Cyclosporin and Methotrexate therapy for maintaining low disease activity in rheumatoid arthritis obtained by 6-8 months of anti-TNF therapy, 21 completed the study with a 6 month follow-up. Thirteen patients maintained clinical parameters within low disease activity values, while 8 patients showed an increase in DAS28 and other parameters. Only two patients showed an increase in blood pressure that was diagnosed after two months from the beginning of the A-Cyclosporin and Methotrexate therapy. The reduction in the dosage of A-Cyclosporin from 3mg/kg/day to 2mg/kg/day caused a slow normalization of blood pressure values. Our data seem to suggest that more than half of the patients undergoing A-Cyclosporin and Methotrexate therapy seemed to maintain low disease activity parameters of rheumatoid arthritis, obtained after 6-8 months of anti-TNF therapy. Further studies on larger populations are necessary in order to confirm such results and identify predictor factors for different responses.

A new technical contribution for ultrasound-guided injections of sacro-iliac joints.

INTRODUCTION: Sacroiliac joint (SIJ) represents a difficult location for local therapies, as intra-articular injections may be hard to execute, especially in particular conditions such as chronic inflammatory diseases. However, in selected patients, local therapies may be considered. Some recent studies demonstrated the feasibility of ultrasound (US)-guided injection of SIJ, but still a complete explanation and definition of the technique is needed. MATERIALS AND METHODS: Seven patients, four males and 3 females, affected by mono or bilateral sacroiliitis entered the study. Each patient received 40 mg of acetonide triamcinolone for each SIJ, intra articular (IA) US-guided injection. The technical originality proposed in this study consists in the spinal needle insertion in the middle of the cranial long side of the linear transducer with an orientation of about 10 degrees, determining shorter needle insertion for reaching joint space and consequently probably granting lesser pain and traumatism for patients. RESULTS: A total of 22 injections was performed. The longer follow-up time obtained was 18 months in 3 patients. All patients reached at least a 6 month follow-up. All patients reported an amelioration in pain that lasted for at least 6 months. No systemic adverse events were reported or observed. Complete visualization of SIJ and of needle placement was performed by US imaging, while compound proper injection was also visualized by Color-Doppler US imaging. DISCUSSION: Actually, sacroiliac joint intraarticular injections are often performed under fluoroscopy or Computerized Tomography guidance. Such techniques present several limitations, especially for repeated injections, such as the use of ionizing radiations, the need of a contrast agent and the direct and indirect costs connected. US guidance in IA SIJ injections may represent an easily repeatable imaging technique for needle placement and a precious tool for detecting inflammatory activity of the joint.

Mixed panniculitis responding to cyclosporin-A with a 12-month follow-up: a case report.

Panniculitides represent a heterogeneous group of inflammatory diseases involving subcutaneous fat. Subcutaneous fat is normally organized into adipose cells, adipocytes, and septa of connective tissue. The inflammation involving such tissues can be more represented in septa (septal panniculitis) or in lobules (lobular panniculitis) or be equally distributed in both (mixed panniculitis). A bioptical study is necessary in order to discern between different forms. Vascular involvement is also different in such diseases, as it can interest arteries, or veins, or both. Different grades of fat necrosis can also be observed, such as adipocytes without nuclei, lipophagic necrosis, liquefactive fat necrosis, microcystic fat necrosis, ischaemic fat necrosis. Panniculitis can be idiopathic or secondary to other diseases such as systemic sclerosis, rheumatoid arthritis, systemic erithematous lupus and many others. Therapies usually vary on the single patient but the general orientation leads to the use of immunosuppressive drugs such as thalidomide, corticosteroids, cyclosporin-A, hydroxychloroquine and cyclophosphamide. We report a case of a 19-year-old female affected by primary mixed panniculitis, associated with fever and deep asthenia, that resolved in a few weeks and was maintained with oral cyclosporin-A.

The safety of anti-TNF agents in the elderly.

Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis are commonly thought of as inflammatory diseases that affect younger individuals. Although the initial presentation of these diseases is common in a patients twenties or thirties, they usually persist for the duration of the patients life. In addition, up to one-third of patients with RA have disease onset after 60 years of age. Anti-TNF-a therapies now have well-recognized safety profiles that have been demonstrated in the usual clinical trial populations for these diseases, but such populations under-represent patients > or =65 years of age. This retrospective study aims to determine the safety profiles for etanercept, infliximab and adalimumab in patients of 65 years or more, undergoing anti-TNF treatment for an active inflammatory disease such as rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis, or skin disease like psoriasis. Our data show that admitting elderly patients into anti-TNF therapeutic regimens is a safe option and that it grants these patients access to the best current therapeutic option, possibly leading to better disease outcome. Quality of life in elderly patients affected by arthritis or psoriasis, often reduced by comorbidities, is as important as quality of life in younger patients. Applying the recommended screening before using biological treatment helps to reduce adverse events related to the therapy, and the application of the same screening in elderly patients seems to lead to comparable results.

Thermal inactivation of the acquired immunodeficiency syndrome virus, human T lymphotropic virus-III/lymphadenopathy-associated virus, with special reference to antihemophilic factor.

The virus that causes the acquired immunodeficiency syndrome (AIDS), human T lymphotropic virus/lymphadenopathy-associated virus (HTLV-III/LAV), was incubated at temperatures from 37 degrees to 60 degrees C and virus titer (ID-50) was determined over time by a microculture infectivity assay. The rate of thermal decay was consistent with first-order kinetics, and these data were used to construct a linear Arrhenius plot (r = 0.99), which was used to determine inactivation time as a function of temperature. In the liquid state, thermal decay was little affected by matrix (culture media, serum, or liquid Factor VIII). In the lyophilized state, the time required to reduce virus titer 10-fold (1 log) at 60 degrees C was 32 min compared with 24 s in the liquid state. HTLV-III/LAV in liquid antihemophilic Factor VIII or IX was lyophilized and heated according to commercial manufacturers' specifications. Infectious virus was undetectable with these regimens. Heat treatment should reduce or stop transmission of HTLV-III/LAV by commercial antihemophilic Factor VIII or IX.

[Correlation between radiologic and ultrasonographic patterns and clinical manifestations in symptomatic hip osteoarthritis]. / Correlazione tra quadro clinico e patterns radiologici ed ecografici in pazienti affetti da artrosi sintomatica dell'anca.

Increasing amounts of data have recently been published regarding ultrasonographic (US) findings of osteoarthritic joints, but very few data concern hip joints. In the current study we described US patterns concerning 490 patients affected by symptomatic hip osteoarthritis (OA) who underwent to intra-articular injections of hyaluronic products under US guidance. All patients were studied by US and X-ray of hip, clinical evaluation was assessed by the followings indexes: Lequesne, pain VAS, ICED, Global Physician Assessment and Global Patient Assessment. US findings were summarized in four main patterns, effusion and synovial proliferation were also detected. The aim of this study was to correlate US findings with clinical assessment and radiographic findings (according to Kellgren-Lawrence classification). Pearson's r correlation coefficient were computed and come out significant and positive between X ray and US patterns and between clinical indexes and US patterns. Also the correlation between K-L score and US patterns showed a significant positive correlation indicating that higher K-L scores are associated with increasing abnormal US findings. Our data suggest that ultrasonography of the hip may give useful information about the state of synovial membrane, synovial fluid, joint margins and bone profile in hip OA. Further studies are needed to evaluate their prevalence in hip OA symptomatic and not-symptomatic patients and their correlation to treatment outcome.

An open randomized active-controlled clinical trial with low-dose SKA cytokines versus DMARDs evaluating low disease activity maintenance in patients with rheumatoid arthritis.

BACKGROUND: Biologic agents are currently the strongest immunosuppressive drugs able to induce remission in rheumatoid arthritis (RA). One of the objectives of the medical scientific community now is how to maintain remission or low disease activity (LDA). The aim of this trial is to evaluate the contribution of low-dose sequential kinetic activation (SKA) IL-4, IL-10, and anti-IL-1 antibodies (10 fg/mL) in patients affected by RA in maintaining LDA or remission obtained after biological therapy. METHOD: This is a randomized, open, active-controlled, prospective, Phase IV trial. Disease activity score (DAS28), clinical disease activity index, simplified disease activity index, erythrocyte sedimentation rate and C-reactive protein levels, global health assessment, and pain visual analog scale were evaluated at baseline visit and then every 3 months together with an assessment of side effects till 12 months. Thirty-nine RA patients were enrolled and randomized to continue disease-modifying antirheumatic drugs (DMARDs) therapy or to receive a combination of SKA low-dose cytokines formulated in concentration of 10 fg/mL orally administered at a dose of 20 drops/d for 12 consecutive months. RESULTS: The rate of maintenance of LDA at 12 months was superior in the group treated with low-dose cytokines compared with patients treated with DMARDs, 66.7% and 42.1%, respectively; however, the difference between the groups was not statistically significant. No side effects were reported in both groups. CONCLUSION: This is the first study using a combination of three low-dose cytokines in RA, after data published on psoriasis. These data suggest that the use of a combination of low-dose SKA cytokines may be an opportunity to explore in the management of RA.

Comparison of methods for assessing chemotaxis of monocytes and polymorphonuclear leukocytes isolated from patients with AIDS or AIDS-related conditions.

We evaluated the ability of normal human peripheral blood monocytes and polymorphonuclear leucocytes (PMNL) isolated from patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related conditions (ARC) to migrate toward a chemoattractant. Migration in blind-well chambers was compared to that under agarose. Chemotaxis results obtained from both assays for PMNL were similar, however there was a difference in the results for monocyte chemotaxis. PMNL isolated from patients with AIDS, but not ARC, exhibited decreased spontaneous and directed chemotaxis when assessed in blind-well chambers and under agarose. Spontaneous and directed chemotaxis in blind-well chambers of AIDS patients' monocytes was normal. Directed migration of monocytes from ARC patients was greater than that of control, but spontaneous migration was comparable. Under agarose, spontaneous migration was depressed in monocytes of AIDS patients, while migration toward the attractant was depressed in those of ARC patients.

Monoclonal antibody to human granulocytes: cellular specificity and functional studies.

Antigenic specificity and functional studies of G2, a monoclonal antibody to human granulocytes, prepared by fusing spleen cells from immunized Balb/c mice to the nonimmunoglobulin (Ig) secretor line SP2/0, are described. The antibody was reactive with the HL60 and K562 cell lines and with human peripheral blood granulocytes; and unreactive toward human lymphocytes, erythrocytes, a variety of T and B cell lines, as well as toward leukemic cells obtained from patients with acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), and acute myelocytic leukemia (AML). The G2 monoclonal antibody identified cell surface antigens on cells from cases of acute myelomonocytic leukemia (AMMoL) and on cells from 2 of 12 cases of acute undifferentiated leukemia (AUL). G2 was capable of inhibiting oxygen consumption by human polymorphonuclear leukocytes (PMNL) stimulated with aggregated human immunoglobulin (IgG), opsonized zymosan, f-met-leu-phe (FMLP), and the calcium ionophore A23187. Inhibition of the PMNL response to phorbol myristate acetate (PMA) and digitonin was dependent upon the dose of the stimulant. G2 should facilitate elucidation of the mechanisms of granulocyte membrane perturbation and subsequent activation of various functions via a selective interaction with key cell surface antigens.

[Intra-articular treatment with Hylan G-F 20 under ultrasound guidance in hip osteoarthritis. Clinical results after 12 months follow-up]. / Terapia intra-articolare con acido ialuronico (Hylan G-F 20) sotto guida ecografica nell'artrosi dell'anca. Risultati clinici a 12 mesi.

Hip is a site very commonly affected by osteoarthritis (OA), yet few data exist in literature regarding intra-articular use of hyaluronic acid in this pathology. We evaluated the efficacy of Hylan G-F 20 hip viscosupplementation performed under ultrasound guidance. We enrolled 26 patients affected by symptomatic hip OA and treated them with a single intraarticular injection of Hylan G-F 20, which could be repeated every two months. The injection was performed under ultrasound guidance with an antero-superior approach. Treatment efficacy was assessed through Lequesne index, visual analogue scale (VAS) pain quantification, and NSAID intake at the timepoint zero (baseline), and after 2, 6 and 12 months. We observed a statistically significant reduction of all considered parameters at the timepoints 2 and 6 months, when compared to baseline. At 12 months the changes were still statistically significant for all parameters for about 50% of the patients. No side effect was observed, nor systemic complication. Viscosupplementation is a promising approach for hip OA, although further and wider studies are wanted to determine how long the beneficial effect lasts, and what is the optimal number of injections to administer.

Studies on the nature of the human platelet alloantigen, PlA1: localization to a 17,000-dalton polypeptide.

We have examined the biochemical properties of the human platelet alloantigen system, PlA, using a preparation enriched in plasma membrane glycoproteins (GPs) IIb and IIIa as the starting material. After confirming that GPIIIa contains the PlA epitope, attempts were made to distinguish the two allelic forms of PlA (A1 and A2) using electrophoretic techniques. Whereas no difference could be discerned in the mol. wt of GPIIIa extracted from A1/A1, A1/A2 or A2/A2 platelets by one-dimensional SDS-polyacrylamide gel electrophoresis (SDS-PAGE), two-dimensional electrophoresis revealed a reproducible difference in the isoelectric point of GPIIIa derived from A2/A2 individuals. Treatment of GPIIIa with a combination of exo- and endoglycosidases resulted in apparently complete deglycosylation of the molecule, as indicated by its co-migration with chemically deglycosylated GPIIIa in SDS-PAGE. The enzymatically deglycosylated protein retained its full ability to react with anti-PlA1 antibodies. Tryptic digestion of GPIIIa resulted in the generation of a number of smaller polypeptides, including one of 17,000 daltons, that contained the PlA1 determinant. These results suggest that the carbohydrate moieties of GPIIIa are unimportant to the expression of the PlA system, and that the charge difference between the two allelic forms of GPIIIa may reflect a subtle amino acid difference(s) within a 17K polypeptide region of the GP.

Immunoassay for the detection and quantitation of infectious human retrovirus, lymphadenopathy-associated virus (LAV).

Detection of replicating human retroviruses has relied upon rather cumbersome reverse transcriptase, immunofluorescence, or electron microscopic assays. We describe a new sandwich enzyme-linked immunoassay (ELISA) for detecting the human retrovirus, lymphadenopathy-associated virus (LAV), in supernates of LAV-infected human lymphocyte cultures. This LAV capture immunoassay compares favorably with the reverse transcriptase assay, despite the fact that it is performed on 20-fold less supernate material. Because the assay can be performed on 0.1 ml of culture supernate and is done by an ELISA method, LAV inoculation of lymphocyte cultures can be monitored quite conveniently, and endpoint titrations of infectious virus (ID-50 assays) can be performed. We demonstrate the application of the capture assay and ID-50 assay to disinfectant and serum neutralization experiments.

Aneuploidy among prenatally detected neural tube defects.

We have reported previously a 10% aneuploidy detection rate among 39 cases of fetal neural tube defects (NTD). Subsequently we amassed an additional experience of over 17,000 prenatal diagnosis cases over a 5-year period. During this period 106 cases of NTDs were identified; 44 with anencephaly, 62 with open spina bifida. The average maternal age of this population with NTDs was 29 years (15-40); 6 patients declined amniocentesis. Six of 100 cytogenetic studies were aneuploid; one anencephalic fetus had inherited a maternal marker chromosome, and 5 NTD cases had trisomy 18. The average maternal age of the aneuploid cases was 31 (19-40); 3 were 35 years or older. Four of 5 trisomy 18 cases had multiple congenital anomalies (MCA). The overall aneuploidy detection rate in our cohort was 5-6%, while aneuploidy occurred in 2% of the isolated NTD cases, and 24% of the MCA cases. Combining the earlier experience, 4/39 aneuploidy (2 trisomy 18, 4p+, del 13q) yields an aneuploidy detection frequency of 10/145 (7%), of which most (7/10) had trisomy 18. These data support fetal karyotyping for accurate diagnosis, prognosis, and recurrence-risk counseling.

Use of infection control guidelines by workers in healthcare facilities to prevent occupational transmission of HBV and HIV: results from a national survey.

OBJECTIVE: Develop national estimates of compliance with infection control guidelines by workers in healthcare facilities to prevent occupational transmission of hepatitis B virus (HBV) and human immunodeficiency virus. DESIGN: A national survey of 3,094 workers in hospitals. SETTINGS: United States ambulatory care hospitals with emergency rooms. RESULTS: While the sampled hospitals had policies that incorporated the Centers for Disease Control and Prevention's (CDC) infection control guidelines, only 55% of patient care staff, 56% of physicians, and 30% of housekeeping staff reported receiving at least one of the shots recommended in the HBV vaccination series. About one half of patient care staff reported that they recapped used needles at least sometimes after giving injections and after drawing blood. Only 43% of patient care staff "always" wore gloves to draw blood. While most patient care staff "always" changed gloves between patients, only 61% reported that they "always" washed their hands after taking off their gloves. One half of patient care staff reported a percutaneous exposure to a patient's blood, and one quarter reported a percutaneous exposure in the past year. The most common cause of these exposures was recapping used needles. CONCLUSIONS: Efforts to reduce exposures to bloodborne pathogens will involve compliance with the Occupational Safety and Health Administration bloodborne pathogens standard and the CDC's infection control guidelines, continued education and training, and emphasis on engineering controls where applicable.