The Continuing Challenge: Hospital Hygiene
The Continuing Challenge: Hospital Hygiene
The Continuing Challenge: Hospital Hygiene
Hospital hygiene:
Combination
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[26 - 31] On show at Arab Health New targets in treating chronic pain
NOTES - the scarless surgery of the future?
Ethical issues in telenursing
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Clostridium difficile:
a challenge for hospitals
A dramatic increase in the frequency about 20% of humans, and some CD strains Changing epidemiology:
and in severity of nosocomial Clostrid- are capable of producing enterotoxins (e.g., an increase in incidence
ium difficile-associated disease has toxins A and B). and virulence
In 2003, a rapid and dramatic increase in the
been noted worldwide. In addition,
CD was first described in 1978 as the cause number of CDAD cases, as well as the sever-
a new and hypervirulent clone has of intestinal diseases following antimicrobial ity of disease, was noticed – even in otherwise
emerged, causing large outbreaks in therapy. Meanwhile, various antibiotic sub- healthy young individuals who had previously
many countries. This article summa- stances have been identified as risk factors not been receiving antimicrobial therapy.
rises the recommendations on infec- for the occurrence of C. difficile-associated Many of these unusual CDAD cases were due
tion control measures from the Euro- disease (CDAD), for example clindamycin, to the emergence of a new and hypervirulent
broad spectrum cephalosporins, and fluoro- CD strain with increased toxin production.
pean Center for Disease Prevention
quinolones. Most patients affected by CDAD This clone (often referred to as ribotype 027/
and Control (ECDC). will only develop rather mild diarrhoea. NAP1/toxinotype III) was first recognised
However, more severe courses of disease, in Canada and the US where it caused large
ending up in pseudo membranous colitis, nosocomial outbreaks. Shortly thereafter the
by Dr Ralf-Peter Vonberg toxic megacolon or even a fatal outcome, pathogen was transmitted to Europe and Asia
are also well documented. In addition to the [1-3]. National and local health departments
above mentioned clinical consequences for enforced or implemented infection control
Microbiological background: the individual there is also an economical guidelines, but despite these efforts the strain
30 years of antibiotic-associated impact of this disease on hospitals and health continued to spread.
diarrhoea care systems. Depending upon the kind of
Clostridium difficile (CD) is an anaerobic, patient population the attributable costs of That is why the European Centre for Dis-
spore-forming, gram-positive rod bacterium. CDAD may range from $3,000 to $10,000 ease Prevention and Control (ECDC) finally
It is part of the physiological gut flora in per case. decided to develop evidence-based guidelines
The user-friendly interface and powerful FlowLab computer software make the FlowAnalyser the
ideal tool for Service, Production and R&D Departments in the respiratory field.
Protective clothing
It is part of standard precautionary measures
to wear gloves and gowns or aprons when
managing patients who have diarrhoea.
Of course this is also true when caring for
patients suffering from CDAD. Once again,
Figure 1. Clostridium difficile. it should be remembered that the immedi-
ate vicinity of the patient is often highly
for the prevention of nosocomial transmission Education of staff, patients contaminated by spores.
of CD and acquisition of CDAD [4]. and visitors
As is true for many other nosocomial infec- Cleaning the immediate
These guidelines are primarily meant to serve tious agents, proper education of all players environment
as a basis for local infection control proto- involved is also highly effective in order to Rooms of CDAD patients should be dis-
cols. They resulted from a systematic search limit the spread of CD. This should include infected regularly using sporocidal agents.
of the literature relating to diagnosis, surveil- physicians, nurses, cleaning personnel, any Other parts of the ward should also be cleaned
lance, education, isolation precautions, hand other staff that enter the patient’s room, at least on a daily basis, concentrating on fre-
hygiene, protective clothing, environmental visitors of the patient, and the patient him/ quently touched areas. In addition immediate
cleaning, use and reprocessing of medical herself. All of these people need to know the cleaning should occur when obvious environ-
equipment, antimicrobial stewardship and basics of spore transmission and the appro- mental contamination has occurred. Toilets,
specific measures in outbreaks. The corre- priate precautions to take, with an emphasis bed pans and commodes are especially likely
sponding recommendations for each topic on hand hygiene. to become contaminated with faeces. Thus
are presented below.
stopped. Specific guidelines on the nosocomial Clostridium diff- difficile-associated disease in and Hospital Epidemiology
treatment of CDAD (e.g., the appli- icile-associated disease during North America and Europe. Medical School Hanover
cation of metronidazole and/or oral an epidemic caused by a hyper- Clin Microbiol Infect 2006;12 Carl-Neuberg-Str. 1
vancomycin) are currently being virulent strain in Quebec. CMAJ Suppl 6:2-18. D-30625 Hanover
discussed and should be published 2005;173:1037-42. 4. Vonberg RP, Kuijper EJ, Wil- Germany
soon. At present there is no recom- 2. Warny M, Pepin J, Fang A, cox MH, Barbut F, Tull P, Gast- Tel: +49 511 532 4431
mendation that favours the use of Killgore G, Thompson A, Bra- meier P et al. Infection control email:
probiotics with CDAD patients. zier J et al. Toxin production by measures to limit the spread Vonberg.Ralf@MH-Hannover.de
an emerging strain of Clostrid- of Clostridium difficile. Clin
Specific measures in ium difficile associated with Microbiol Infect 2008;14 Suppl
outbreaks outbreaks of severe disease in 5:2-20. Comments
Infection control staff should North America and Europe.
always be informed immediately Lancet 2005;366:1079-84. The author on this article?
please feel free to post them at
an outbreak of CDAD is sus- 3. Kuijper EJ, Coignard B, Tull Ralf-Peter Vonberg, MD www.ihe-online.com/comment/Hospitalhygiene
pected, and all infection control P. Emergence of Clostridium Institute for Medical Microbiology
measures should then be rein-
forced. When doing so, the stand-
ard of cleaning the immediate
environment should be particu-
larly reviewed. A critical review
of the current antimicrobial
Conclusions
We have to face the fact that,
more than ever, CDAD represents
an emerging threat in all kinds of
medical departments. Because of
the clinical and financial burden
resulting from this disease, all
efforts should be made to mini- Single Use Creatinine Biosensor
mise the risk of nosocomial CD
spread. Already existing infection Virtually Painless Fingerstick Capillary Sample , 1.2 µL
control protocols should therefore Fast, 30 Second Analysis
be carefully reviewed and modi-
Wide Measurement Range 0.3-12 mg/dL (27-1056µmol/L)
fied if necessary. In addition, the
staff on the ward must always be Calculated eGFR and Creatinine Clearance
aware of the possibility of CDAD
in diarrhoeal patients, and strict
adherence to infection control
measures is highly recommended
as soon as CDAD is diagnosed. IN THE U.S., call toll-free 800-458-5813 or 781-894-0800 • IN CANADA, call toll-free 800-263-5999
www.novabiomedical.com/ihe1208.htm
References
1. Pepin J, Valiquette L, Cossette
B. Mortality attributable to
www.ihe-online.com & search 45099
– Issue N°7 – Dec. 2008 - Jan. 2009 8 Hospital hygiene - news
UK Hospitals to be fined millions should be introduced to avoid misdiagnosis by reducing the number of time-consum-
and its consequences. These are the conclu- ing reference method tests that would be
sions of a review on the effectiveness of com- necessary in the second stage. Estimating the
monly used C. difficile test kits, to be pub- extra first-stage costs at £10,000-£30,000 per
lished in the December edition of The Lancet year, they add: “We predict the savings in
Infectious Diseases. The paper was written antibiotic costs, the enhanced use of isolation
by Professor Sanjeev Krishna and colleagues facilities, reduced burden on infection con-
at St George’s University of London and St trol, and reduced cases of C. difficile associ-
George’s Healthcare NHS Trust, London, UK. ated diarrhoea across the hospital will offset
The consequences of a misdiagnosis can be these additional laboratory expenditures.”
severe - tests that give false positive results http://press.thelancet.com/tlidcdiff.pdf
can lead to antibiotic treatment for other
conditions being stopped, patients treated Nanotechnology paints for
inappropriately for C. difficile infection, hospitals could kill superbugs
and isolation with other C. difficile patients,
which can then lead to them contracting the
NHS Hospital Trusts in the UK that are suc- condition. Tests that give a false negative
cessful in reducing Clostridium difficile risks result will mean the patient will not get the
in line with government targets still have a C. difficile treatment they require, leading to
50% chance of paying a financial penalty more serious illness and possible infection of
every year, and around a 95% chance of being patients in close proximity. Most brands of
fined over three years, warn researchers writ- hospital testing kits detect a C. difficile toxin
ing for the British Medical Journal. Sarah (CDT) in a patient’s stool sample. However,
Walker and colleagues from research institutes the researchers show in the review that cur-
in Oxford, Cambridge, and London, UK, say a rent tests on the market have proportions of
recent initiative to encourage Trusts to reduce positive results that are false from 3-45%,
C. difficile infections has resulted in a perverse and proportions of true positives that are
incentive where, in the worst case situation, missed from 5-24%. Whilst the tests were
Trusts can be heavily penalised if they go over similar in their accuracy, some were more
the set target by just a single extra case, and, likely to return a false positive result, whereas
in general, penalties are very hard to avoid others were more likely to miss a case — such
completely. Penalties may involve millions variation makes comparisons of C. difficile
of pounds, for example, a 2% fine of a large prevalence in different UK health trusts diffi- New nanotechnology paints for walls, ceil-
Trust with a revenue of £500 million could be cult (since different trusts use different kits). ings and surfaces could be used to kill hos-
around £10 million. The authors explain that To improve diagnostic accuracy, the authors pital superbugs when fluorescent lights are
the problem with the current penalty system propose a new two-stage testing system. Stage switched on. The new paints contain tiny
is the way targets and financial penalties are one would be an initial, rapid, highly sensitive particles of titanium dioxide, which is the
applied to Trusts. The NHS contract does not screening assay carried on the day of receipt dazzling white compound often used as a
distinguish between the underlying risk of of the patient’s stool sample; this would detect brightener in commercial paints. It will also
each new patient getting C. difficile, which nearly all positives and mean that confirmed be familiar to tennis fans as the powder used
they want to reduce by about 10% a year, and negative results are issued promptly. The sec- for the white lines to mark out the courts at
the actual count of cases observed in a par- ond stage would then be a confirmatory test Wimbledon. Scientists have discovered that
ticular Trust—this is only an approximate that would weed out the false positives using extremely small, nanoparticle-sized forms
measure of the underlying risk, particularly in the current, reference method and provide a of titanium dioxide can kill bacteria and
smaller Trusts. Even if this underlying risk is definitive result within 2-5 days. The authors destroy dirt when they absorb ultraviolet
reduced by the right amount, for a relatively claim that the additional costs incurred by light (UV) energy from the sun. They pro-
rare event like C. difficile the play of chance the proposed new first stage could be offset duce active molecules which clean up the
means that the actual number of cases seen painted surfaces. The researchers from Man-
may be higher or lower than this. In addition, chester Metropolitan University, UK, looked
the penalties are uneven. In the worst case sce- at the survival of the potentially food poi-
nario, a Trust with 199 cases of C. difficile in soning bacterium Escherichia coli on dif-
the previous year and 199 cases in the actual ferent formulations of paints containing
year will escape penalty. However, if the Trust the titanium nanoparticles under different
reaches 200 cases it is automatically fined 2% types and intensities of lights. With rising
of its revenue because the 10% target reduc- concern about the spread of hospital super-
tion (179 cases) has not been achieved by a bugs, healthcare trusts are increasingly look-
margin of 10% or more. Thus a single case ing to find better ways to maintain hygienic
could cost a trust millions of pounds. standards in hospitals. The same concerns
http://www.bmj.com/channels/news.dtl are driving developments in the food indus-
try and in pharmaceutical companies. These
C. difficile tests not accurate new nanoparticle paints could provide a
Current hospital tests for the bacterium simple and cost-effective solution.
Clostridium difficile (C. difficile) are not https://www.sgm.ac.uk/news/releases/
accurate enough and a new two-stage process MTNG.0908.LC.1.cfm
9 – Issue N°7 – Dec. 2008 - Jan. 2009
Light activated treatments solve problem for thousands of hospital patients contamination have been reported on doc-
MRSA problems after surgery every year, and up to 9% of hospital acquired tors’ stethoscopes and pens.” However,
infections occur during surgery, contributing research has shown that patients don’t like
to 77% of deaths from surgical operations. to see surgeons walking around in what they
The latest work from the University College perceive as casual clothing - they feel more
London team shows that even with very low confident of their professional competence
oxygen levels in the damaged tissues, most when they see them in white coats.
dangerous bacteria can still be killed using the
light-activated dyes.
https://www.sgm.ac.uk/news/releases/
MTNG.0908.GO.1.cfm
Geriatric anesthesiology
2nd Edition
Ed by J.H Silverstein, G.A This major revision of the classic anaes- knowledge and recent breakthroughs of
Rooke, J.G. Reves and C.H thesia text features recent advancements as importance to any who work with the elderly.
McLeskey. well as expanded coverage of classic topics For the second edition, the editors have intro-
Pub. by Springer (2008), in the rapidly growing and evolving field of duced a streamlined chapter format and have
440 pages, e89.95 geriatric anaesthesia. assembled a selection of chapters intended
The last few years have seen significant to deepen the understanding of anaesthesic
advancements in and important new modali- management of the geriatric patient.
ties for addressing the needs of an ageing pop-
ulation. The editors of Geriatric Anesthesiol- Springer-Verlag GmbH
ogy’s second edition are uniquely situated to Heidelberg, Germany
put together a text highlighting both essential www.ihe-online.com & search 45127
Year book of
anesthesiology and
pain management, 2008
Elsevier
Oxford, UK
www.ihe-online.com & search 45128
www.ihe-online.com & search 45101
– Issue N°7 – Dec. 2008 - Jan. 2009 12 Anaesthesiology
perivascular microglia following the treatment started day five after the release of proinflammatory cal utility as an opioid adjuvant
peripheral nerve injury. nerve injury; and (3) inhibited the mediators into the synaptic milieu to decrease dose escalation and
production of proinflammatory and prevents neuronal sensitisa- adverse opioid side effects.
Additionally, CBR2 reduces the cytokines such as IL-1b, IL-6 and tion, the pathological correlate to
number and regulates the function TNFa in the L5 lumbar spinal cord chronic pain. Finally, we have shown that pro-
of infiltrating T-leukocytes into the in association with the reversal of pentofylline, an atypical methylx-
brain in rodent models of multi- hyperalgaesia and allodynia [13]. Ibudilast is a non-selective PDE anthine has been shown to signifi-
ple sclerosis. This CBR2 action is We recently also showed a novel inhibitor that decreases CNS CR3/ cantly decrease neuropathic pain
significant since T-leukocyte and effect of minocycline: it inhibits CD11b and GFAP expression fol- behaviours and associated glial
macrophage trafficking into the microglial motility by reducing lowing nerve injury or morphine reactivity and cytokine expres-
CNS following peripheral nerve b1 integrin expression and Kv1.3 administration. Ibudilast has been sion [14]. Propentofylline has been
injury is instrumental for the main- channel activity and expression. shown to enhance morphine anal- shown to reduce proliferation and
tenance of microglial activation We propose that reducing micro- gaesia while decreasing morphine migration [15]. The specific mech-
and pain. Our findings thus suggest glial trafficking to injured neurons tolerance and morphine withdrawal anism of its anti-nociceptive effects
that CBR2 provide an attractive following nerve injury decreases symptoms and thus may have clini- remains unknown. However,
target that may pharmacologically
act to induce a spinal microglial
anti-inflammatory phenotype.
Minocycline, a semisynthetic
second-generation tetracycline,
is an antibiotic that possesses
superior penetration through the
brain-blood barrier and into the
CNS [12]. Minocycline is a potent
inhibitor of microglial reactiv-
ity and has no direct action on
astrocytes or neurons in vitro. We
have shown in a rat model of neu-
ropathic pain that minocycline:
1) reversed the development of
mechanical allodynia and hyperal-
gesia but did not produce an effect
on existing behavioral hypersen-
sitivity; (2) prevented increased
spinal microglial CR3/CD11b
and GFAP expression in the pre-
emptive treatment, but inhibited
only microglial reactivity when
www.ihe-online.com & search 44945
– Issue N°7 – Dec. 2008 - Jan. 2009 14 Anaesthesiology
NOTES –
scarless surgery of the future
Laparoscopy has made many procedures less invasive, NOTES horizons
however, today it seems that this is not enough. The new- NOTES includes transgastric, transvaginal, transcolonic, transrec-
est challenge for the medical environment is applying the tal or transvesical access to the peritoneal cavity or even the tho-
rax. Up until now several NOTES applications in humans have been
technique of scarless surgery in humans. This is achieved by
reported, but most of the documented NOTES procedures have been
Natural Orifice Transluminal Endoscopic Surgery (NOTES), performed on animal models. On the other hand, NOTES-like pro-
in which access to the peritoneal cavity is achieved and cedures, such as PEG, endoscopic pancreatic pseudocyst drainage
some procedures are feasible through natural orifices or needle puncture of structures through the gastric wall have been
such as the digestive tract, vagina or urinary bladder. If practised for years. The debridement of infected necrotic pancreatic tissue is
the safety and advantages of these approaches can be another example of the minimally invasive management of a life-threaten-
ing state, which can decrease postoperative morbidity and mortality. A small
proved beyond question, NOTES procedures are likely to
series of transgastric appendectomies, fallopian tubal ligations and cholecys-
be adapted in humans after overcoming critical obstacles, tectomies in humans has been reported. The first totally NOTES procedure
such as reliable closure methods, indispensable equipment was performed by a French team from IRCAD. The initial clinical trial of a
invention, the training of multidisciplinary specialists, etc.
In summary, NOTES is currently the subject of intensive
research. It seems like it is only a matter of time before
transluminal access to the abdominal or even the thoracic
cavity will become a reality.
Electrocardiographs
Medicine has taken an enormous step from the performance of life-
saving open surgery to minimally-invasive surgery that not only assures
Patient monitors
survival, but also a relatively good quality of life. The general accept-
ance of laparoscopic surgery has made many procedures less invasive,
safer and cosmetically more acceptable. The idea of scarless surgery has
now become a great challenge for the whole medical environment.
The history of NOTES begins in 1901, when Dimitri Oskarovich Ott per- January 2009
formed the first endoscopic examination of the peritoneal cavity through Improve your 'Good Sense of Health' and visit us at Arab Health
the vagina. Endoluminal diagnostic endoscopy has gradually advanced
Join us at the MPC corridor - Hall 3E20
over the years to include endoluminal surgery. Initially, endoscopy was a
tool used for diagnostics, but the therapeutic approach soon became well-
accepted. A combined technique utilising the endoscope and percutaneus
tools in order to place the gastrostomy tube (PEG) in stomach extended Thermometers
the endoscopic paradigm outside the gastrointestinal tract.
Step counters
S7350 Transvaginal and transgastric approaches were The general advantage of the development of
ELECTRONIC also applied to nephrectomy [9,32]. The out- NOTES is also the competition the technique gen-
SCALE come of these methods is very encouraging. erates, which can facilitate improved laparoscopic
Kidney resection was successful and no clinical and endoscopic surgery by encouraging specialists
www.ihe-online.com & search 44996
17 – Issue N°7 – Dec. 2008 - Jan. 2009
to improve their skills [2]. Even if this technique What is certain is that for some aspects, such as techniques for new era. Gastrointestinal
does not prove to be as safe and useful as it cosmetic effects or post-operative pain, trans- Endoscopy 2007;66:340-342.
appears, some surgical fields will benefit from the luminal procedures will always be superior to 2. Swain P. A justification for NOTES – nat-
research efforts put into developing the technique classic open surgery or even to laparoscopic ural orifice translumenal endosurgery.
and advances will be made enabling the inven- methods. However, some features of NOTES Gastrointest Endosc 2007; 65(3):514-516.
tion of phenomenal, modern equipment such as are not yet considered to be as beneficial for 3. G ettman MT, Lotan Y, Napper CA, et al.
thinner, more effective flexible endoscopes. the patient as laparoscopic techniques [2]. Transvaginal laparoscopic nephrectomy:
development and feasibility in the por-
Challenges Summary cine model Urology 2002; 59(3):446-450.
- optimal technique for peritoneal access Laparoscopy has brought enormous changes to 4. Wallace MB. Take NOTES (Natural Ori-
- gastric closure (risk of a leak); sutures, clips traditional open techniques, however, translu- fice Transluminal Endoscopic Surgery).
or endoscopic stapler minal endoscopic surgery will gain its own place Gastroenterology 2006; 131:11-12.
- risk of peritoneal infection, abscess after in the field of surgery in the near future. The 5. Columbia physicians perform first US
puncturing gastric wall rapid development of the NOTES technique is a transvaginal cholecystectomy. Available
- spatial orientation (retroflexed endoscope) necessity, considering the advantages that it can at: www.columbiasurgery.org/news/si/
- team work of surgeons and bring. The possibility of performing truly scar- index.html [Accessed June 4, 2007].
gastroenterologists less, safe, more effective and , at the same time, 6. European Association for Transluminal
- physiology of pneumoperitoneum (carbon less painful and minimally invasive surgery is Surgery, http://www.eats.fr
dioxide?), intraperitoneal pressure control very tempting for doctors. What is actually more 7. Kalloo AN, Singh VK, Jagannath SB,
- training important, is that the benefits for patients will et al. Flexible transgastric peritoneos-
The surgical application that could revo- encourage the medical world to make every copy: a novel approach to diagnostic and
lutionise the position of NOTES globally effort to realise the potential of NOTES. therapeutic interventions in the perito-
are cholecystectomy, and possibly bariatric neal cavity. Gastrointest Endosc 2004;
procedures and fallopian tubal ligation [2, 36]. If References 60:114-117.
the new methods and procedures can be proved 1. Valdivieso E, Saenz R, Claudio N. Natu- 8. Schauer P, Chand B, Brethauer S. New appli-
to be safe and effective, they may provide a new ral orifice transluminal endoscopic sur- cations for endoscopy: the emerging field
dimension to minimally invasive surgery [36]. gery: putting together minimally invasive of endoluminal and transgastric bariatric
surgery. Endosc Surg 2007; 21: 347-356.
care. NOSCAR received 32 grant applications Gastric Lesions Using a Novel Grasp-and- Arab Health Dubai
for the $750,000 in research funds. Snare Technique: Evaluation in a Porcine stand ZS80
Survival Model
The first NOSCAR Research Awards were - Michael Marohn, DO, Johns Hopkins
announced in 2006. Since that time, 56 University School of Medicine, Baltimore,
grants have been awarded. Recipients of MD
the 2008 awards are conducting research Immune & Baseline Alterations on the
in both animal models and humans. Physiologic Response to Natural Orifice
Past NOSCAR Research Award winners Translumenal Endoscopic Surgery (NOTES):
recently presented data from their projects A Comparison Between Human Transvaginal
at the 3rd International Conference on and Laparoscopic Cholecystectomy.
LA-6440
NOTES held in San Francisco, CA, USA, LARYNGEAL MASKS
language and face expressions. This means nurse describes it, this is “walking a fine line, 9. Kaplan B et al. Cambridge Quarterly of
that decisions must be based only on the ver- both ethically and as a fellow human being” Health Care Ethics 2008;17:401-416.
bal information the caller chooses to reveal. [10, p.1869]. 10. Holmström I et al. Journal of Clinical
Further, the nurse can never be fully sure of Nursing 2007;16,:1865-1871.
the caller’s identity, in spite of the fact that Ethical competence building in 11. Kälvemark Sporrong S et al. Nursing Ethics
the caller gives a name and a social security telenursing 2007;14:825-837.
number. This raises the ethical question of how As ethical dilemmas occur frequently in telen-
to ensure the caller’s integrity within telenurs- ursing the question of ethical competence build- The authors
ing. One way to handle this dilemma is by being ing in this context is urgent. Nurses’ individual Anna T. Höglund, Ph.D., Associate Professor,
restrictive about information on previous ill- qualities, as well as the organisational climate, Inger Holmström, R.N., Ph.D., Associate
ness and calls. Furthermore, a telenurse should are important aspects to address in this discus- Professor,
be cautious when sensitive information is to be sion. Ethical competence is both an individual Centre for Research Ethics and Bioethics,
documented, for example, when calls concern and an organisational responsibility in the Department of Public Health and Caring
psychiatric illness or venereology/gynaecology. healthcare system. In order to be able to identify Sciences, Uppsala University, Sweden
On such occasions, a telenurse may just note if a dilemma is truly ethical in nature, as well as Anna.Hoglund@crb.uu.se
‘referral’ in the record, which is a correct but to be able to judge and act upon it, high ethical Inger.Holmstrom@pubcare.uu.se
not very informative notation. competence is needed among nurses.
Priority setting and the One way to achieve this could be to work with Comments on this article?
Feel free to post them at
healthcare organisation so called ethics rounds, i.e., a form of institu-
As a telenurse can be described as being both a tionalised, interprofessional ethics discussions www.ihe-online.com/comment/Telenursing
healthcare adviser and a “gate-keeper”, priority [11]. In addition to the increased ethical com-
setting is part of the day-to-day work in telen- petence that might come out of such ethics
ursing. In Sweden, priorities should be made rounds, a decrease in moral uncertainty and
according to a platform consisting of three ethi- moral distress might also follow.
cal principles, namely the principles of human FAZZINI s.r.l.
s.s. Padana Superiore 317
dignity, need and solidarity, as well as cost-effi- Conclusions 20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
ciency. This ethical platform has been adopted The identified ethical dilemmas in telenursing Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
by the Swedish parliament and is also inscribed also occur in other forms of nursing. However, www.fazzini.it
in the Swedish Health and Medical Services Act. telenursing might be particularly sensitive to
ethics. For example, respect for autonomy and
Priority decisions have been shown to create obtaining informed consent might be difficult Arab Health Dubai
stand ZS80
several dilemmas for telenurses. They experi- when a woman calls in for her spouse, respect
ence concerns about the healthcare organi- for integrity might be difficult in both the
sation and the fact that certain patients “fall information and the documentation process,
F-208
ULTRASONIC
through the safety net” as they are constantly and the balancing of giving the patient hon- PROFESSIONAL
referred, for example, from the GP to a psychi- est information with the ethical demand to NEBULIZER
atric clinic, back to the GP, etc. In these situ- avoid harm, are all examples of ethical dilem- ON TROLLEY
ations the principle of cost-efficiency collides mas that telenurses handle in their daily work.
with the principle of human dignity. Telenurses Hence, ethical competence building and ethi-
can experience this as extremely unethical and cal discussions on a regularly basis are needed
also develop moral distress symptoms. They for telenurses.
want to give care, but the organisational struc- www.ihe-online.com & search 44993
tures hinder them from following through on References
the preferred course of action. 1. M arklund B et al. Journal of Nursign
Management 2007;15:180-7.
Responsibility and information 2. H olmström I. Nursing and Health Sciences
FAZZINI s.r.l.
Ethical dilemmas in telenursing can also occur 2007;9:23-8. s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
due to the nurses’ obligation to inform the 3. S nooks H et al. The development of tel- Tel. ++39/02265152-1
patient and at the same time avoid giving too enursing. Journal of Advanced Nursing Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
much information that might overwhelm the 2008;61:631-40. www.fazzini.it
patient and make him/her deny the symptoms. 4. Holmström I et al. Scandinavian Journal of Arab Health Dubai
Here, the ethical demand of presenting honest Caring Sciences 2002;16:142-48. stand ZS80
information to the patient might clash with the 5. Wahlberg A. Telephone Advice Nursing. Call-
principle of non-maleficence. An example of a ers’ perceptions, nurses’ experience of prob-
situation that may create this dilemma is when lems and basis for assessments. Karolinska
a patient calls in for what s/he believes is a small Institute, 2004.
problem, needing only some advice on self-care, 6. B eauchamp TL et al. Principles of Biomedi-
while the nurse apprehends thatthe symptoms cal Ethics. 6th edition. New York: Oxford
described are signs of a serious illness. The tel- University Press, 2008.
enurse feels that s/he cannot confront the caller 7. Wolf R, Zuzelo PR. Quality Health Research
with the truth too abruptly, but s/he must at 2006;16:1191-1206. F-202
the same time try to make the caller realise the 8. R aines M. JONA’s Healthcare, Law, Ethics ULTRASONIC NEBULIZER
severity and urgency of the symptoms. As one and Regulation 2000;2:29-41.
www.ihe-online.com & search 44991
– Issue N°7 – Dec. 2008 - Jan. 2009 20 HEALTHCARE IT
Managed services:
are they really cost-effective for storing,
sharing and distributing images?
When it comes to imaging infrastruc- Healthcare data follow the same trend, with the storage solution. When dealing with an archiv-
tures, healthcare providers are facing volume of information either produced digitally ing infrastructure, we can even consider that
numerous challenges and it is tempt- or digitalised increasing. This is particularly true the proportion is lower, and that the costs
in imaging departments with several cumula- of maintaining information accessible dur-
ing to transfer responsibility of IT
tive phenomena contributing to growth. New ing tens of years are largely underestimated
activities with their associated risks generation CT and MR machines are produc- by IT organisations.
and burden to a third party. Subscrib- ing a larger number of heavier images. The vol- Let us consider a classical archiving infrastruc-
ing to a managed service to store, ume of images per exam is therefore so large ture and list the mandatory tasks required to
share and distribute healthcare images that new tools are necessary to improve diag- maintain the minimum service levels required
from a hosted platform sounds like a nostic efficiency. At the same time these CT by users.
and MR technologies are more popular, and
good alternative. But will it be more
increasingly used for diagnosis. Hardware and software maintenance
expensive than if the organisation This is provided by the technology suppliers and
does this itself? How does this relate Retention time also impacts on volume: legal usually covers problem fixing in a reactive mode
to increasing cost pressures in the requirements have evolved making it now with on-site support and software updates.
healthcare sector? critical to be able to present images in case of
requests from the authorities. Daily infrastructure monitoring
In order to make sure that the system is working
by Bernard Algayres Collaborative work properly, daily monitoring is important.
Collaboration is now the new way of working - At the hardware infrastructure level: this
in all industries and this is also true in health- means insuring that no hardware compo-
The challenges care: patients often receive critical care from nent such as a RAID disk or a tape library
Volume explosion multiple healthcare facilities (e.g. chronic is damaged.
Globally, the volume of digital information is disease treatment requiring coordination - At the application level: all the processes
exploding. Recent reports from the IT mar- of different specialties). As a result, patient that run the archiving application must
ket intelligence provider, IDC (March 2008) data may be scattered among various clinical be working properly, particularly manage-
show that the volume of digital information systems across multiple sites with no simple ment of the database that is the kernel of
produced will multiply by 10 between 2006 access to aggregated historical records. The the system. This task requires a very good
and 2011. Another IT advisory company, lack of healthcare professionals in a number knowledge of the archiving application itself.
Gartner is expecting a 69% annual capacity of specialties also increases the need to easily - At the data level: it is critical to ensure data
growth in this period, an even higher growth access patient information from any location. protection through the backup or replica-
than was expected earlier. tion processes, data security through the
Demanding healthcare professionals analysis of access logs to the data, and data
Healthcare professionals are under pres- integrity. This part is key to guarantee long
sure: they need to provide the best care in a term preservation.
reduced- cost environment. Access to the lat-
est clinical tools and optimising workflow is Problem management
FAZZINI s.r.l.
s.s. Padana Superiore 317 therefore key. In addition to their traditional This covers all the tasks related to the occur-
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1 activity of setting up IT infrastructures, hos- rence of a problem, including:
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
pital IT professionals need to act as real busi- 1. Problem detection and identification: identi-
www.fazzini.it ness consultants, understanding the needs of fication of the exact source of the problem
healthcare professionals in order to find the 2. Escalation process management: having the
Arab Health Dubai
stand ZS80
right solutions. right supplier handling the problem with the
proper level of priority.
The cost impact 3. Resolution management: implementation of
Long-term preservation of information is one the fixes by the supplier, testing and accept-
of the most challenging parts of the hospital IT ance of the fix, and communication with the
organisation. Healthcare organisations trying to users impacted by the problem.
find the best solution for keeping data available 4. Hardware and software update/upgrade
over a 10 to 15 year period of time often consider management: although software upgrades
investment as the main portion of their costs. A may be part of a supplier maintenance
SB100 number of studies contradict this. Gartner esti- contract, the hospital IT has to manage the
PULSOXIMETER mates that capital costs count for less than 20% process, including:
of the Total Cost of Ownership (TCO) of a - Management of the supplier intervention
www.ihe-online.com & search 44998
21 – Issue N°7 – Dec. 2008 - Jan. 2009
Infrastructure provisioning
Given the exponential growth, hardware and
software provisioning must be addressed
regularly. It may require a re-design of the
infrastructure if not properly designed at the
beginning, or when the infrastructure reaches
its capacity. Provisioning covers:
- New capacities: costs here include both new
investments and management costs to mini-
mise impact on users, and to communicate
with them. If not anticipated, it can also lead
to downtime costs.
- New applications that need access to data:
during the life of an archive, new applications
such as patient record systems, new adminis-
trative systems or new clinical tools will need
access to data. Figure 1. Obsolescence management and migration: the combination of obsolescence and volume of
data, and the complexity that will increase when volume grows.
Obsolescence management
This is certainly the most difficult part and will Figure 1 illustrates the combination of obsoles- impact occurs on production. Figure 2 gives an
become increasingly complex over time. As we cence and volume of data, and the complexity illustration of this.
have all experienced, technology renewal rate that will increase when volume grows.
in IT is usually between three to five years. In the standard break and fix service model,
Knowing that retention time of data is close The Managed Services path problems are detected by users (white curve),
to 20 years, it means that each component of As we have seen, the healthcare IT environment usually when it is too late and system opera-
the infrastructure will require changing four is becoming more and more challenging, with tions are seriously degraded. During this
to seven times during the lifetime of informa- data volume growth and increasing informa- period, it takes time to analyse the problem
tion, with possible associated migrations. As tion access requirements. At the same time, and investigate root causes, and system down
soon as obsolescence occurs different costs the management of the clinical data repository time usually happens where situations may not
have to be taken into account: necessitates more and more resources, with be fully recoverable, leading in extreme cases to
- Re-investment: the system has to be renewed high level expertise in storage technologies, data loss. This is typically the case for systems
and new systems must be integrated in database management, network and security. resource overloading or exhaustion: disk reach-
the infrastructure ing limits, no more tape for backups or server
- Migration costs: all ingested data in the How can managed services be overloaded by migration.
archive need to be moved to the new sys- cost effective?
tem. Over time, and as volumes of infor- • Proactive monitoring Thanks to Managed Services monitoring
mation grow, migrating data can become The proactive monitoring approach enables the resources and tools, problems can be detected
a real issue. early detection of potential problems before any in a very early phase (green curve) by the
• Technology
Technology is the basis of a reliable and cost
effective service offer. It is designed for service
and fulfills the following criteria:
- Flexibility: the technology must be able to
handle different configuration mixing both
on site and off site storage.
- High availability: this is what will allow the
supplier to guarantee service levels.
- Multidimensional scalability: the technol-
ogy must be incrementally scalable in capac-
ity, performance, storage technologies and
application connectivity. This incremental
scalability is key for cost efficiency.
Figure 2. The proactive monitoring approach.
-E
nhanced connectivity: the solution must Conclusion
interconnect through different protocols to Archive systems are complex systems that com-
different applications from different vendors. bine servers, databases and a variety of storage
FAZZINI s.r.l. - s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
-C
linical information lifecycle management: subsystems, often over several locations. They
Tel. ++39/02265152-1 - Fax ++39/0227409242 this is particularly important in order to must be maintained over long period of time.
e. mail: fazzini @ fazzini.it ~ www.fazzini.it
optimise cost and ease migration. Hospitals often consider managed services as a
Arab Health Dubai way to offload their IT department and trans-
stand ZS80
• Organisation fer storage management tasks to a third party.
Providing a managed services offer requires a However, when looking at the cost aspects, they
dedicated organisation, which must employ are usually surprised that their real internal
highly skilled experts who are always available costs are much higher than thought, and that
to make sure that the system is optimised in managed services are a way to save costs.
terms of availability, security and performance.
Advanced monitoring tools are also key in order In addition, managed services reduce the risk
to ensure the quick detection of any issue, the of system unavailability or data loss thanks to
immediate preliminary diagnostic, and quick permanent monitoring. Also, collecting infor-
involvement of the right level of expertise. mation from different sites to be stored and
SA210 preserved on a datacentre broadens access and
PULSOXYMETER Costing evaluation distribution of images as these activities can
General considerations be achieved direct from the datacentre with
www.ihe-online.com & search 44997 We have seen that analysts consider that in the enhanced security, instead of opening each
Total Cost of Ownership of a classical storage hospital site to the external world.
infrastructure, the investment costs are less than
20% of the total cost. This means that a $200k Rather than investing in infrastructure, health-
infrastructure will finally cost $1M in a five year care is increasingly following industry trends
FAZZINI s.r.l.
s.s. Padana Superiore 317 period plus migration costs. Experience shows by subscribing to services on a pay as you go
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1 that these costs are under evaluated. basis with service level agreements. Carestream
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
Health with its eHealth Managed Services, is at
www.fazzini.it Migration costs the leading edge of this movement.
Arab Health Dubai Based on different studies across different envi-
stand ZS80 ronments, estimation is that the cost for migra- The author
tion is around $5 000 per terabyte and that due Bernard Algayres
to obsolescence, 25% of the volume is moved General Manager
each year. This shows that the total obsoles- eHealth Managed Services
cence costs can become a real problem. A hos- Carestream Health
pital, say producing 250 000 annual studies for www.carestreamhealth.com
an equivalent of 25 Terabyte of uncompressed www.ihe-online.com & search 45125
data/12 Terabyte compressed, would incur
yearly migration costs of around $100 000 at
Comments on this article?
F-X50 year seven, $150 000 at year 10 and $225 000 at
Feel free to post them at
MOBILE SUCTION PUMP year 15. This excludes the volume growth for
www.ihe-online.com/comment/IT
this specific example.
www.ihe-online.com & search 44994
News in brief 23 – Issue N°7 – Dec. 2008 - Jan. 2009
Med
Tel
Inconsiderate bosses not only make work stressful, they may also increase
the risk of heart disease for their employees, experts believe. A Swedish
team found a strong link between poor leadership and the risk of seri-
ous heart disease and heart attacks among more than 3,000 employed
men. And the effect may be cumulative - the risk went up the longer
an employee worked for the same company. The study is published in
the scientific journal Occupational and Environmental Medicine. Previ-
ous work has shown that unfair bosses can drive up their employees’
LUXEMBOURG
blood pressure, and persistent high blood pressure can increase heart
disease risk. For the latest study, researchers from the Karolinska Insti-
tute and Stockholm University tracked the heart health of the male
employees, aged between 19 and 70 and working in the Stockholm area,
over a period of nearly a decade. During this time 74 cases of fatal and
non-fatal heart attack or acute angina, or death from ischaemic heart
disease, occurred. All the participants were asked to rate the leadership THE INTERNATIONAL eHEALTH,
style of their senior managers on competencies such as how clearly they
set out goals for their staff and how good they were at communicating TELEMEDICINE AND HEALTH ICT FORUM
and giving feedback. Feeling undervalued and unsupported can cause For Education, Networking and Business
stress, which often leads to unhealthy behaviours - adding to the risk of
developing heart problems. The findings held true, regardless of educa-
tional attainment, social class, income, workload, lifestyle factors, such
as smoking and exercise, and other risk factors for heart disease, such
as high blood pressure and diabetes. The researchers, which included
experts from University College London in the UK and the Finnish Insti-
tute of Occupational Health, said that if a direct cause and effect was
confirmed, then managers’ behaviour should be targeted in a bid to stave
off serious heart disease among less senior employees. They said manag-
ers should give employees clear work objectives and sufficient power in
relation to their responsibilities.
http://news.bbc.co.uk/2/hi/health/7745324.stm
professor in the Department of Neuroscience, model mice given the complex orally. In its lat- the benefits of the scan far outweigh the risk of
Baylor College of Medicine in Houston, Texas. est study the team found that the orally admin- cochlear implant demagnetisation.
In his prize-winning essay, Costa-Mattioli istered complex also lowered glucose levels in http://www.entnet.org/
describes how he and his colleagues found a type 1 model mice, offering hope for an injec-
type of molecular switch in mice that “deter- tion-free treatment for people with type 1 dia- Liver disease research investment
mines” whether a long-term memory is made betes. The vanadyl complex of garlic-compound
from an experience. “I decided to focus my allixin lowers blood glucose in diabetes mod-
research on eIF2-alpha since it regulates two els. The new study looked primarily at how the
fundamental processes which are critical for allixin complex works. By examining the effects
the formation of long-lasting memories: new of the complex on genes affected by diabetes, the
protein synthesis and the activity of a memory researchers found that it activates not only the
repressor protein, ATF4,” he said. When the insulin signalling cascade, which regulates glu-
neuron protein eIF2-alpha is activated, it sup- cose metabolism, but also an enzyme that helps
presses a neuron’s production of other proteins cells to absorb glucose. The researchers say that
that allow the brain to form long-lasting mem- the allixin and similar complexes could be good
ories. Costa-Mattioli investigated eIF2-alpha’s candidates for treating both type 1 and type
role in the formation of long-term memories 2 diabetes. Future work, says Sakurai, will be
and in long-term potentiation by studying aimed towards clinical trials of these complexes
mice with reduced eIF2-alpha activity. These in human diabetes patients.
mice appeared to have improved spatial mem- http://www.rsc.org/AboutUs/News/PressRe-
ory - they learned to remember the location of leases/2008/GarlicDiabetes.asp
a hidden platform in a pool faster than nor-
mal mice did - and the synaptic connections MRI machines may damage
between their neurons lasted for longer than cochlear implants
those of normal mice. The grand prize winner Patients with cochlear implants may want A new £1m clinical research facility dedicated
receives $25,000 from Eppendorf, and the win- to steer clear of certain magnetic imaging to tackling liver disease, the fifth most common
ner’s essay, “Switching memories ON and OFF,” devices, such as 3T MRI machines, because cause of death in the UK, opens this month at
is published in the November 2008 issue of the the machines can demagnetise the patient’s Imperial College London. Liver disease death
journal Science. implant, according to new research published rates are rising in the UK, in contrast to other
www.sciencemag.org/feature/data/prizes/eppen- in the December 2008 issue of Otolaryngol- common diseases such as heart disease and can-
dorf/eppenprize.shtml ogy – Head and Neck Surgery. The study, con- cer, and the new Robert Hesketh Hepatology
ducted by a team of German and American Clinical Research Facility aims to provide care and
Diabetes treatment without jabs? researchers, tested several cochlear device mag- develop new therapies to reverse this trend. The
nets on a 3T MRI scanner with active shielding unit will accommodate fifty researchers, doctors
at a variety of angles (0º, 80º, 90º, 100º, 110º, and nurses from Imperial College London and
and 180º). The researchers discovered that dur- Imperial College Healthcare NHS Trust, work-
ing routine use of 3T MRI machines at angles ing together to help liver patients. In addition to
above 80º, an unacceptable level of demagneti- providing the best possible care for thousands of
sation was reached, causing permanent damage patients, staff at the unit aim to better understand
to devices with non-removable magnets, and liver disease. All of the patients will be offered
creating the potential of exposing patients to the opportunity to take part in the unit’s clinical
undesirable magnetic forces. As a result of their research programmes and some will be able to
findings, the study authors recommend that enrol in its clinical trials. These will address the
MRI scans on patients with cochlear implants four main causes of liver disease – alcohol, fatty
should be performed using a 3T MRI machine liver disease and chronic hepatitis B and C – as
only if a 1.5T machine is not available, and if well as liver cell and bile duct cancers. Blood, liver
and DNA samples taken from patients as part
A compound found in garlic is the basis of a of routine care will be used to develop ways of
potential orally-available drug candidate for predicting which patients will develop the severe
types 1 and 2 diabetes. Diabetes incidence is complications of liver disease. Researchers at the
increasing worldwide, and there is a continuing unit will wage a war on liver disease on a number
need to develop effective treatments. Exisiting of fronts. They will examine why some people are
treatments involve either injection with insu- genetically predisposed to alcoholism, a condi-
lin (primarily for sufferers of type 1 diabetes), tion which is responsible for 70% of chronic liver
or treatment with drugs (for type 2 diabetes). disease. They will also be looking at the genetic
However, neither method is ideal, says Hiromu reasons why some people are more susceptible to
Sakurai, of the Suzuka University of Medical Sci- fatty liver disease than others, and why some of
ence, Japan, as they involve frequent injections, these people will progress from fatty liver disease
and the drugs have undesirable side-effects. In to hepatitis and cirrhosis. In addition, they will
earlier work, Sakurai’s group had shown that a be exploring how factors such as alcohol and diet
complex of vanadium and allixin, a compound can exacerbate viral liver disease.
found in garlic, lowered blood glucose levels in http://www3.imperial.ac.uk/newsandeventspg-
mouse models of both types 1 and 2 diabetes grp/imperialcollege/newssummary/news_1-12-
and that the effect was maintained for type 2 2008-14-0-7?newsid=50894
News in brief 25 – Issue N°7 – Dec. 2008 - Jan. 2009
Anetic Aid
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Arnsberg, Germany drug classes are available after just five min-
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reduce the number of cost- and time-intensive
Innovative operating theatre laboratory blood tests. The system comprises
equipment two main components: the Dräger DrugTest
5000 Analyser and the Dräger DrugTest 5000
Test Kit. After the protective cap has been
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ple is taken from the patient’s mouth. As soon
as sufficient saliva has been gathered in the test
kit for analysis, the built-in indicator turns
Arab Health Dubai blue. The operator then places the test cassette
stand ZS80
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result is “positive” or “negative” for every drug
class on its colour display. Acoustic signals
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entire procedure. Due to its simple operation,
the test is far more discreet and hygienic for
both patients and operators than urine-based
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On show at Arab Health 27 – Issue N°7 – Dec. 2008 - Jan. 2009
Agfa Healthcare
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Enraf-Nonius B.V.
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Philips Healthcare
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– Issue N°7 – Dec. 2008 - Jan. 2009 32 PRODUCT NEWS
Portable digital clinical assistant can be made even more durable by upgrading to
The MICA-101 is a a solid-state drive (SSD), which adds total pro-
fanless clinical assist- tection from accidential shock and bumps. The
ant system incorpo- MICA-101 is rugged, portable and lightweight,
rating a 1.1/1.6 GHz with an ergonomic carry handle allowing medi-
Intel Atom Proces- cal professionals to carry it easily throughout
sor. The new device an entire shift. Its resistance to spills and drips
provides an optimal has earned it Ingress Protection (IP54) certifica-
balance between high tion. For aseptic practice, it can be wiped clean
performance and very with disinfectant.
low noise — perfect
for bedside care and Advantech Europe GmbH
clinical environments. The Intel Atom proces- München, Germany load to the desired level. The EC-12S provides
sor, with ultra low power consumption, extends www.ihe-online.com & search 45132 continuous evaluation through high precision
battery operating time to five hours and so helps ST and rhythm analysis and by the automatic
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care. The 10.4” display, with Intel Integrated 3D Low power electrosurgical unit Interpretation of the results — available both
Graphics, utilises a passive resistive and active with monopolar/bipolar modes on screen and on print-out — is facilitated
digitiser touchscreen and fully supports hand- by colour-coded graphs and tables. The user-
writing via a stylus pen. Storage needs are met by friendly product is small, light, battery operated
a hard disk drive DD of 60 GB capacity. Storage and has Bluetooth connection capabilities.
Labtech Ltd
Debrecen, Hungary
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The HandTutor system is a rehabilitation pro-
gram which helps stroke patients to relearn
Wireless stress test ECG systems motor skills. Wearing a specially developed
Both the resting and stress test ECG systems glove, which acts like a computer mouse,
from Labtech operate under a common ana- the patient can move characters on a screen
lytical software, which supports network oper- through a series of flexion and extension move-
ation and uses an integrated database for the ments. The controlled, repetitive exercises,
whole of the company’s product family. The conducted in a stimulating virtual reality envi-
universal analysis SW model provides ECG ronment, accelerate the rehabilitation of post-
recordings on 12 simultaneous channels with stroke patients. In order to perform everyday
a precise automatic QRS detection, efficient ST tasks such as grasping a glass or picking up a
and arrhythmia analysis, colour-coded display book, the stroke patient has to relearn motor
Arab Health Dubai
stand ZS80
and print-out in several languages. Recorded skills damaged following the stroke and so it
data can be exported, imported or archived. is necessary to learn how to correctly control
The EC-12S stress test system provides a 3/6/12 the movement of each finger and wrist. As the
channel ECG and blood pressure monitor, HandTutor rehabilitation program improves
so is ideal for diagnostic exercise testing. The motor control impairments, it allows the
whole examination is continuously monitored, patient to start to perform and gain maximum
including multi-level event monitoring and benefit from functional task exercises, which
alarming as well as the possibility of setting the are used during traditional post-stroke hand
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PRODUCT NEWS 33 – Issue N°7 – Dec. 2008 - Jan. 2009
MediTouch,
Netanya, Israel
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Calendar of events
January 26-29, 2009 April 18-21, 2009
Arab Health CMEF Spring 2009
Dubai, Shenzen, China
United Arab Emirates Tel. +86 10 62028899
Tel. +971 4 3365161 Fax +86 10 82022922
Fax +971 4 3364021 http://en.cmef.com.cn
e-mail:
Mustafa.Iqbal@iirme.com June 2-5, 2009
www.arabhealthonline.com Hospitalar 2009
São Paulo, Brazil
March 6-10, 2009 www.hospitalar.com/ingles
ECR - European Congress
of Radiology 2009 June 3-6, 2009
Vienna, Austria EFORT Congress 2009
Tel. +43 1 533 40 640 Vienna, Austria
Fax +43 1 533 40 64448 Tel. +41 44 448 4400
e-mail: Fax +41 44 448 4411
communications@myESR.org e-mail: event@efort.org
www.myESR.org www.efort.org
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