Volume 34 Issue 7

IHE Dec. 2008 - Jan. 2009

Weekly news updates on

www.ihe-online.com
New! Post-a-comment on feature
articles: see inside

Hospital hygiene:

the continuing challenge

Also in this issue:
New targets in treating chronic pain
NOTES - the scarless surgery of the future?
Ethical issues in telenursing

Combination
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physiotherapy
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 Editor’s Letter 3 – Issue N°7 – Dec. 2008 - Jan. 2009

The never-ending story of statins

As befits a JUPITER trial (New England nearly 18000 patients, had to be looks as though there could
class of drugs Journal of Medicine, Nov 2008; stopped prematurely since the shortly be yet another indication
that has had 359, 2195) used elevated levels benefit to the treated patients for prescribing statins.
a huge impact of hsCRP as a trigger for the use far outweighed that in the pla-
on one of of statins rather than LDL cho- cebo group in terms of the com-
the most lesterol levels. In fact, the trial bined end-point of myocardial
deadly condi- purposely excluded patients with infarction, stroke or death from
tions affect- high LDL levels — only normo- cardiovascular diseases. Comments
ing modern populations, namely lipidaemic subjects with high Although there were some draw-
cardiovascular disease, statins serum hsCRP levels were enrolled backs in the study, e.g. an appar-
on this article?
please feel free to post them at
are one of the most intensively in the trial. The results were spec- ently higher incidence of diabetes www.ihe-online.com/comment/statins_hsCRP
studied drugs ever. In addition to tacular. The trial, which involved in the treated group, it nevertheless
innumerable evaluations of safety
and side-effects, there have been
a huge number of clinical studies
on the actual efficacy of the lipid-
lowering drugs. Way back in what
now seems pre-history, one of the
first questions asked was of course
whether the observed physiologi-
cal lowering of serum LDL levels
in subjects with hyperlipidaemia
actually resulted in a lowering of
the incidence of cardiovascular
events. Answer: an emphatic yes.
Then came the question: down to
what levels should the LDL cho-
lesterol levels be driven? Answer:
the lower the better, or at least to
around the normal level of 130mg/
dL. These and literally hundreds
of other trials have firmly estab-
lished statins as an indispensable
tool in the treatment of hyper-
lipidaemic patients, initially only
those with a high cardiovascular
risk although over the years this
has been expanded to include
patients with progressively lower
risk, including those with no pre-
vious history of cardiovascular
disease. The common factor in
all these trials was that the deci-
sion to initiate statin therapy
was based on initial LDL choles-
terol levels, although the precise
threshold level varied from trial
to trial. However elevated LDL
cholesterol is only one of many
markers of cardiovascular dis-
ease, albeit the most important.
The fact remains that nearly half
of all first cardiovascular events
occur in people whose LDL cho-
lesterol levels are below current
thresholds for lipid-lowering
therapy and who would there-
fore a priori not be considered
for statin therapy.
In a novel approach, the investi-
gators in the recently published
www.ihe-online.com & search 45046
 Contents
FRONT COVER PRODUCTS
[27] Total breast
imaging suite
FEATURES
[5 - 9] HOSPITAL HYGIENE
[5 - 7] Clostridium difficile: a challenge for hospitals
[8 - 9] News update
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The ethical issues involved in the use of publication as to whether they are registered or not.
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of images? Cardiology Special

For submission of editorial material, contact

REGULARS Alan Barclay at a.barclay@panglobal.be
[3] Editor’s letter For advertising information, go online to
Volume 34 Issue 7
IHE Dec. 2008 - Jan. 2009

[11] Book review Weekly news updates on

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and ‘Media Information’ or contact
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[23 - 25] News in brief

HOSPITAL HYGIENE:

the continuing challenge Astrid Wydouw at a.wydouw@panglobal.be

Also in this issue:

[26 - 31] On show at Arab Health New targets in treating chronic pain
NOTES - the scarless surgery of the future?
Ethical issues in telenursing

[32 - 33] Product News

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 Hospital hygiene 5 – Issue N°7 – Dec. 2008 - Jan. 2009

Clostridium difficile:
a challenge for hospitals
A dramatic increase in the frequency
and in severity of nosocomial Clostrid-
ium difficile-associated disease has
been noted worldwide. In addition,
a new and hypervirulent clone has
emerged, causing large outbreaks in
many countries. This article summa-
rises the recommendations on infec-
tion control measures from the Euro-
pean Center for Disease Prevention
and Control (ECDC).
by Dr Ralf-Peter Vonberg
Microbiological background:
30 years of antibiotic-associated
diarrhoea
Clostridium difficile (CD) is an anaerobic,
spore-forming, gram-positive rod bacterium.
It is part of the physiological gut flora in
about 20% of humans, and some CD strains
are capable of producing enterotoxins (e.g.,
toxins A and B).
CD was first described in 1978 as the cause
of intestinal diseases following antimicrobial
therapy. Meanwhile, various antibiotic sub-
stances have been identified as risk factors
for the occurrence of C. difficile-associated
disease (CDAD), for example clindamycin,
broad spectrum cephalosporins, and fluoro-
quinolones. Most patients affected by CDAD
will only develop rather mild diarrhoea.
However, more severe courses of disease,
ending up in pseudo membranous colitis,
toxic megacolon or even a fatal outcome,
are also well documented. In addition to the
above mentioned clinical consequences for
the individual there is also an economical
impact of this disease on hospitals and health
care systems. Depending upon the kind of
patient population the attributable costs of
CDAD may range from $3,000 to $10,000
per case.
Changing epidemiology:
an increase in incidence
and virulence
In 2003, a rapid and dramatic increase in the
number of CDAD cases, as well as the sever-
ity of disease, was noticed – even in otherwise
healthy young individuals who had previously
not been receiving antimicrobial therapy.
Many of these unusual CDAD cases were due
to the emergence of a new and hypervirulent
CD strain with increased toxin production.
This clone (often referred to as ribotype 027/
NAP1/toxinotype III) was first recognised
in Canada and the US where it caused large
nosocomial outbreaks. Shortly thereafter the
pathogen was transmitted to Europe and Asia
[1-3]. National and local health departments
enforced or implemented infection control
guidelines, but despite these efforts the strain
continued to spread.
That is why the European Centre for Dis-
ease Prevention and Control (ECDC) finally
decided to develop evidence-based guidelines

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206x132cm_10_2008_final.indd 1 11.12.2008 17:06:35
 – Issue N°7 – Dec. 2008 - Jan. 2009
Figure 1. Clostridium difficile.
for the prevention of nosocomial transmission
of CD and acquisition of CDAD [4].
These guidelines are primarily meant to serve
as a basis for local infection control proto-
cols. They resulted from a systematic search
of the literature relating to diagnosis, surveil-
lance, education, isolation precautions, hand
hygiene, protective clothing, environmental
cleaning, use and reprocessing of medical
equipment, antimicrobial stewardship and
specific measures in outbreaks. The corre-
sponding recommendations for each topic
are presented below.
Early diagnosis of CDAD
Each case of nosocomial diarrhoea should
raise suspicion of CDAD and the appropriate
microbiological diagnostic test should be per-
formed. This includes toxin ELISA and/or cul-
turing of CD. It may also be necessary to retain
cultured isolates in case retrospective typing
of the strains is required. There is no need for
repeated testing of stool samples once CD has
been diagnosed.
Because CD is part of the normal gut flora,
screening cultures should only be carried out
in symptomatic patients (with diarrhoea). For
the same reason, a “test of cure” after symptoms
are resolved is not recommended.
Surveillance of CDAD
Routine surveillance of CDAD cases should
be carried out in all hospitals. As patients’
underlying disease may influence the like-
lihood of CDAD, wards should determine
their unit-specific baseline incidence of
CDAD and should also define a threshold
that would trigger additional control inter-
ventions. Hospital staff should be especially
aware of any rapid changes in the incidence
rate, the frequency of complications due to
CDAD, or the number of extraordinarily
severe CDAD cases. All of these signs may
indicate the introduction of a hypervirulent
CD strain.
6 Hospital hygiene
Education of staff, patients
and visitors
As is true for many other nosocomial infec-
tious agents, proper education of all players
involved is also highly effective in order to
limit the spread of CD. This should include
physicians, nurses, cleaning personnel, any
other staff that enter the patient’s room,
visitors of the patient, and the patient him/
herself. All of these people need to know the
basics of spore transmission and the appro-
priate precautions to take, with an emphasis
on hand hygiene.
Bacterial spores are highly resistant in the
environment; for example, alcohol does not kill spores
such as those produced by Clostridium difficile.
Isolation precautions
Symptomatic patients with CDAD should
be isolated in single rooms whenever possi-
ble. During an episode of diarrhoea, a large
numbers of vegetative bacteria and bacterial
spores are excreted. Thus, a designated toi-
let for the CDAD patient only should also be
provided. If the number of affected patients
is too high to provide single patient rooms,
isolation in cohorts should be undertaken.
Sometimes the implementation of a com-
plete CDAD ward that is run by designated
staff may be helpful in order to prevent
further transmission.
Isolation precautions may be discontinued
48 hours after the symptoms of CDAD have
resolved and bowel movements have returned
to normal.
Hand hygiene
As already mentioned CD is a spore form-
ing bacterium. Bacterial spores are highly
resistant in the environment. It is important
to note that alcohol does not kill bacterial
spores. Therefore, alcohol-based hand rubs
should not be the only hand hygiene measure
employed when dealing with CDAD patients.
Instead meticulous hand washing with soap
and water is recommended for all staff after
a potential contamination of their hands by
CD spores. At present there is no recommen-
dation for the use of antiseptic-containing
soap formulae.
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,
it should be remembered that the immedi-
ate vicinity of the patient is often highly
contaminated by spores.
Cleaning the immediate
environment
Rooms of CDAD patients should be dis-
infected regularly using sporocidal agents.
Other parts of the ward should also be cleaned
at least on a daily basis, concentrating on fre-
quently touched areas. In addition immediate
cleaning should occur when obvious environ-
mental contamination has occurred. Toilets,
bed pans and commodes are especially likely
to become contaminated with faeces. Thus
these items must be scrupulously cleaned.
After the discharge of a CDAD patient, a
thorough disinfection of the patient’s room
is recommended before admission of the next
patient takes place.
Use of medical equipment
Patient-specific use of all medical equipment
such as blood pressure cuffs is strongly recom-
mended. In particular, electronic thermom-
eters should not be shared between different
patients, even if disposable sheaths have been
employed. All such devices should always be
carefully cleaned and disinfected using a spo-
rocidal agent immediately after use with a
CDAD patient. The use of disposable materi-
als should be considered whenever possible
instead of reprocessing multiple-use items.
Antimicrobial stewardship
The use of “high-risk” substances that somehow
select for CD, such as broad spectrum cepha-
losporins, clindamycin and fluoroquinolones
should be avoided. If possible, any antimicro-
bial treatment that does not cover CD as soon
as possible after the onset of CDAD should be
 7 – Issue N°7 – Dec. 2008 - Jan. 2009

stopped. Specific guidelines on the
treatment of CDAD (e.g., the appli-
cation of metronidazole and/or oral
vancomycin) are currently being
discussed and should be published
soon. At present there is no recom-
mendation that favours the use of
probiotics with CDAD patients.
Specific measures in
outbreaks
Infection control staff should
always be informed immediately
an outbreak of CDAD is sus-
pected, and all infection control
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
nosocomial Clostridium diff-
icile-associated disease during
an epidemic caused by a hyper-
virulent strain in Quebec. CMAJ
2005;173:1037-42.
2. Warny M, Pepin J, Fang A,
Killgore G, Thompson A, Bra-
zier J et al. Toxin production by
an emerging strain of Clostrid-
ium difficile associated with
outbreaks of severe disease in
North America and Europe.
Lancet 2005;366:1079-84.
3. Kuijper EJ, Coignard B, Tull
P. Emergence of Clostridium
difficile-associated disease in
North America and Europe.
Clin Microbiol Infect 2006;12
Suppl 6:2-18.
4. Vonberg RP, Kuijper EJ, Wil-
cox MH, Barbut F, Tull P, Gast-
meier P et al. Infection control
measures to limit the spread
of Clostridium difficile. Clin
Microbiol Infect 2008;14 Suppl
5:2-20.
The author
Ralf-Peter Vonberg, MD
Institute for Medical Microbiology
and Hospital Epidemiology
Medical School Hanover
Carl-Neuberg-Str. 1
D-30625 Hanover
Germany
Tel: +49 511 532 4431
email:
Vonberg.Ralf@MH-Hannover.de
Comments
on this article?
please feel free to post them at
www.ihe-online.com/comment/Hospitalhygiene

Point-of-Care Whole Blood Creatinine and eGFR Testing

treatment policy of the patients
on the ward should also be per-
formed. CD can be cultured at
the same time as microbiological
diagnostic tests are performed,
and the samples can be stored for
subsequent molecular typing of
the strains involved. This can help
to elucidate the epidemiology
of the outbreak.

Interim policies for patient

admissions, placement and
(dedicated) staffing should be
administered. Sometimes the
entire unit must be closed for
new admissions or even vacated
for an intensive environmental
cleaning before re-opening.

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
UK Hospitals to be fined millions
NHS Hospital Trusts in the UK that are suc-
cessful in reducing Clostridium difficile risks
in line with government targets still have a
50% chance of paying a financial penalty
every year, and around a 95% chance of being
fined over three years, warn researchers writ-
ing for the British Medical Journal. Sarah
Walker and colleagues from research institutes
in Oxford, Cambridge, and London, UK, say a
recent initiative to encourage Trusts to reduce
C. difficile infections has resulted in a perverse
incentive where, in the worst case situation,
Trusts can be heavily penalised if they go over
the set target by just a single extra case, and,
in general, penalties are very hard to avoid
completely. Penalties may involve millions
of pounds, for example, a 2% fine of a large
Trust with a revenue of £500 million could be
around £10 million. The authors explain that
the problem with the current penalty system
is the way targets and financial penalties are
applied to Trusts. The NHS contract does not
distinguish between the underlying risk of
each new patient getting C. difficile, which
they want to reduce by about 10% a year, and
the actual count of cases observed in a par-
ticular Trust—this is only an approximate
measure of the underlying risk, particularly in
smaller Trusts. Even if this underlying risk is
reduced by the right amount, for a relatively
rare event like C. difficile the play of chance
means that the actual number of cases seen
may be higher or lower than this. In addition,
the penalties are uneven. In the worst case sce-
nario, a Trust with 199 cases of C. difficile in
the previous year and 199 cases in the actual
year will escape penalty. However, if the Trust
reaches 200 cases it is automatically fined 2%
of its revenue because the 10% target reduc-
tion (179 cases) has not been achieved by a
margin of 10% or more. Thus a single case
could cost a trust millions of pounds.
http://www.bmj.com/channels/news.dtl
C. difficile tests not accurate
Current hospital tests for the bacterium
Clostridium difficile (C. difficile) are not
accurate enough and a new two-stage process
8 Hospital hygiene - news
should be introduced to avoid misdiagnosis
and its consequences. These are the conclu-
sions of a review on the effectiveness of com-
monly used C. difficile test kits, to be pub-
lished in the December edition of The Lancet
Infectious Diseases. The paper was written
by Professor Sanjeev Krishna and colleagues
at St George’s University of London and St
George’s Healthcare NHS Trust, London, UK.
The consequences of a misdiagnosis can be
severe - tests that give false positive results
can lead to antibiotic treatment for other
conditions being stopped, patients treated
inappropriately for C. difficile infection,
and isolation with other C. difficile patients,
which can then lead to them contracting the
condition. Tests that give a false negative
result will mean the patient will not get the
C. difficile treatment they require, leading to
more serious illness and possible infection of
patients in close proximity. Most brands of
hospital testing kits detect a C. difficile toxin
(CDT) in a patient’s stool sample. However,
the researchers show in the review that cur-
rent tests on the market have proportions of
positive results that are false from 3-45%,
and proportions of true positives that are
missed from 5-24%. Whilst the tests were
similar in their accuracy, some were more
likely to return a false positive result, whereas
others were more likely to miss a case — such
variation makes comparisons of C. difficile
prevalence in different UK health trusts diffi-
cult (since different trusts use different kits).
To improve diagnostic accuracy, the authors
propose a new two-stage testing system. Stage
one would be an initial, rapid, highly sensitive
screening assay carried on the day of receipt
of the patient’s stool sample; this would detect
nearly all positives and mean that confirmed
negative results are issued promptly. The sec-
ond stage would then be a confirmatory test
that would weed out the false positives using
the current, reference method and provide a
definitive result within 2-5 days. The authors
claim that the additional costs incurred by
the proposed new first stage could be offset
by reducing the number of time-consum-
ing reference method tests that would be
necessary in the second stage. Estimating the
extra first-stage costs at £10,000-£30,000 per
year, they add: “We predict the savings in
antibiotic costs, the enhanced use of isolation
facilities, reduced burden on infection con-
trol, and reduced cases of C. difficile associ-
ated diarrhoea across the hospital will offset
these additional laboratory expenditures.”
http://press.thelancet.com/tlidcdiff.pdf
Nanotechnology paints for
hospitals could kill superbugs
New nanotechnology paints for walls, ceil-
ings and surfaces could be used to kill hos-
pital superbugs when fluorescent lights are
switched on. The new paints contain tiny
particles of titanium dioxide, which is the
dazzling white compound often used as a
brightener in commercial paints. It will also
be familiar to tennis fans as the powder used
for the white lines to mark out the courts at
Wimbledon. Scientists have discovered that
extremely small, nanoparticle-sized forms
of titanium dioxide can kill bacteria and
destroy dirt when they absorb ultraviolet
light (UV) energy from the sun. They pro-
duce active molecules which clean up the
painted surfaces. The researchers from Man-
chester Metropolitan University, UK, looked
at the survival of the potentially food poi-
soning bacterium Escherichia coli on dif-
ferent formulations of paints containing
the titanium nanoparticles under different
types and intensities of lights. With rising
concern about the spread of hospital super-
bugs, healthcare trusts are increasingly look-
ing to find better ways to maintain hygienic
standards in hospitals. The same concerns
are driving developments in the food indus-
try and in pharmaceutical companies. These
new nanoparticle paints could provide a
simple and cost-effective solution.
https://www.sgm.ac.uk/news/releases/
MTNG.0908.LC.1.cfm
 9 – Issue N°7 – Dec. 2008 - Jan. 2009

Light activated treatments solve
MRSA problems after surgery
problem for thousands of hospital patients
every year, and up to 9% of hospital acquired
infections occur during surgery, contributing
to 77% of deaths from surgical operations.
The latest work from the University College
London team shows that even with very low
oxygen levels in the damaged tissues, most
dangerous bacteria can still be killed using the
light-activated dyes.
https://www.sgm.ac.uk/news/releases/
MTNG.0908.GO.1.cfm
contamination have been reported on doc-
tors’ stethoscopes and pens.” However,
research has shown that patients don’t like
to see surgeons walking around in what they
perceive as casual clothing - they feel more
confident of their professional competence
when they see them in white coats.

‘Bare below the elbows’ rule

Killer dyes that can wipe out bacteria could
help solve the superbug problems faced by
surgical patients according to researchers from
University College London, UK. Near-infrared
light is commonly used in fibre-optics and tel-
ecommunications because it passes through
glass easily. Researchers have now discovered
that it can be used alongside a dye to kill bac-
teria that infect wounds and burns. The dye
used, namely indocyanine green, is harmless
to humans and inactive in the dark. However,
it gives off toxic molecules that rapidly kill the
bacteria when it is triggered by the right light
wavelengths. Infected wounds are a major
Should surgeons be bare below the elbows and
tieless? Or are new UK dress rules for doc-
tors compromising their professional image
without sufficient evidence that hospital-
acquired infections will be reduced? That’s
the question posed by urology consultant Mr
Adam Jones from the Royal Berkshire Hos-
pital, Reading, UK, in the September issue of
BJU International. Charting the history and
attire of surgeons from the early nineteenth
century, he points out that it is hard to find
significant evidence that the ‘bare below the
elbows’ rule outside the operating theatre
will reduce hospital-acquired infections like
MRSA and C. difficile.
“The evidence for the roles of ties, shirt cuffs,
rings or watches in infection is hard to find
and mostly in obscure medical journals” says
Mr Jones. “Indeed similar levels of bacterial http://www.bjui.org/

www.ihe-online.com & search 44789

 OnlInE REgIStRAtIOn
Oct 1, 2008 – Feb 23, 2009
myESR.org/registration_ECR2009

Facts & Figures

Oceania
0.52% South
Asia America
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11.70% 0.72%

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America 2.85%
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Africa
0.70%
• 1,800 Accepted Proffered Papers and Exhibits: and
Western Eastern and
Europe
rejection rate: 66 % 59%
Southern
Europe
• Fully Electronic Scientific Exhibition 24.51%

• Industrial Exhibition on 26,000 m². 285 exhibitors ECR 2008

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 Book reviews 11 – Issue N°7 – Dec. 2008 - Jan. 2009

Geriatric anesthesiology
2nd Edition
Ed by J.H Silverstein, G.A This major revision of the classic anaes-
Rooke, J.G. Reves and C.H thesia text features recent advancements as
McLeskey. well as expanded coverage of classic topics
Pub. by Springer (2008), in the rapidly growing and evolving field of
440 pages, e89.95 geriatric anaesthesia.
The last few years have seen significant
advancements in and important new modali-
ties for addressing the needs of an ageing pop-
ulation. The editors of Geriatric Anesthesiol-
ogy’s second edition are uniquely situated to
put together a text highlighting both essential
knowledge and recent breakthroughs of
importance to any who work with the elderly.
For the second edition, the editors have intro-
duced a streamlined chapter format and have
assembled a selection of chapters intended
to deepen the understanding of anaesthesic
management of the geriatric patient.
Springer-Verlag GmbH
Heidelberg, Germany
www.ihe-online.com & search 45127

Year book of
anesthesiology and
pain management, 2008

by David Chestnut, MD,

Alfred Habeeb Professor and

Chair of Anesthesiology,
Professor of Obstetrics and Gynecology,
University of Alabama School of Medicine,
Birmingham, AL,
USA
Pub. by Elsevier (2008),
320 pages, e86.99

The Year book of Anesthesiol-

ogy and Pain Management pro-
vides abstracts of the articles that
reported the year’s breakthrough
developments in anesthesiology.
These have been carefully selected
from more than 500 journals
worldwide. Expert commentaries
evaluate the clinical importance
of each article and discuss its
application to practice.

Elsevier
Oxford, UK
www.ihe-online.com & search 45128
www.ihe-online.com & search 45101
 – Issue N°7 – Dec. 2008 - Jan. 2009 12
Glial cell functions:
new targets to treat pain
Chronic pain is the most difficult pain to
treat. Current analgesics are modestly
effective, have significant side effects and
do not provide universal efficacy. Herein,
we describe the role of glia in neuropathic
pain and opioid tolerance, and describe
novel targets that may provide superior
efficacy and wider therapeutic indices.
by Dr E A Romero-Sandoval,
R J Horvath & Dr J A DeLeo
An estimated 100 million people in the U.S.
alone suffer from chronic pain. Neuropathic
pain, chronic pain associated with nerve injury
is one of the most difficult types of pain to
treat. Opioids as well as newer agents, such as
calcium channel a2-d ligands, tricyclic anti-
depressants and selective serotonin/norepine-
phrine reuptake inhibitors, have significant
side effects and do not provide universal effi-
cacy. Thus, there is a need for the development
of new agents for the treatment and prevention
of chronic pain states. Attention has recently
shifted from neuronal modulation to the dis-
covery of glial modulating agents for the treat-
ment of a host of neurodegenerative diseases,
as well as chronic pain.
Glial cells and pain
Glial cells, including resident microglia, perivas-
cular microglia, astrocytes and oligodendro-
cytes constitute over 70% of the total cell popu-
lation in the brain and spinal cord. Glial cells
are key neuromodulatory, neurotrophic and
neuroimmune elements in the CNS. Microglia,
cells of monocytic origin, are the macrophages
of the brain and the first cell type to respond
to CNS injury. The initial signal that triggers
microglial reactivity is not fully understood;
however, neuronal depolarisation and extracel-
lular ion changes following nerve injury may be
major stimuli. Alternatively, neuronal signals
such as nitric oxide (NO) or pro-inflammatory
cytokines may induce this reactivity. We have
postulated that TLR4 and CD14 may be the
“receptor complex” for these activating signals
from neurons [1-3].
Microglia both release and respond to several
cytokines including interleukin (IL)-1, IL-6,
tumour necrosis factor (TNF)a, and interferon-g
all of which are instrumental in astrocytic reactivity,
Anaesthesiology
induction of cellular adhesion molecule expres-
sion and recruitment of T-leukocytes into the
lesion. In addition, microglia may act as cytotoxic
effector cells by releasing proteases, reactive oxygen
intermediates and NO. Perivascular microglia are
CNS antigen-presenting cells and play an impor-
tant role in the communication of the CNS with
the peripheral immune system, especially in path-
ological conditions [4] such as neuropathic pain.
Perivascular microglia shed or express the anti-
inflammatory surface marker, ED2/CD163. Of
relevance to chronic pain states, we have reported
that spinal ED2/CD163 expression is reduced
following peripheral nerve injury [5].
Astrocytic changes in response to injury include
proliferation, hypertrophy, and over-expression of
glial fibrillary acidic protein (GFAP). Spinal GFAP
increases following peripheral nerve injury. We
have demonstrated that peripheral nerve injury
induces an early microglial activation as assessed
by ITGAM, TLR4 and CD14 mRNA followed by
a delayed but sustained GFAP mRNA expression.
Interestingly, we also showed increases in spinal
CR3/CD11b protein, a microglial marker, at days
28 and 42 after nerve injury. These findings suggest
that the therapeutic window in which glial modu-
lating agents may be utilised may be broader than
originally speculated.
Relatedly, it has been proposed that (MMP)-9 in
DRG sensory neurons, MMP-2 in satellite cells
and spinal astrocytes, and astrocytic expres-
sion of the extracelluar signal-regulated kinase
MAP kinase play a key role in neuropathic pain
development and maintenance. These recent
studies underscore the value in investigating
functional glial properties versus the simple
observation of morphological reactivity.
Opioids – the current gold standard
Opioids are among the most potent analge-
sic agents available for clinical use and are the
gold standard for treating acute, post-surgical
and cancer pain. However, their use in neu-
ropathic pain is often limited by the develop-
ment of analgesic tolerance and unwanted side
effects which are unmasked during the result-
ing dose escalation. Much of the early research
on combating opioid tolerance focused on
determining potential neuronal mechanisms
of tolerance formation and designing opioid
analogues with improved tolerance profiles but
with disappointing results in clinical trials.
Song and Zhao [6] have identified a casual link
between glial activation and morphine tolerance.
We have shown that chronic morphine adminis-
tration induces analgesic tolerance, and increases
the expression of spinal CR3/CD11b, a micro-
glia marker, GFAP an astrocyte marker, and the
cytokines IL-1a, IL-6 and TNFa. We have shown
that both inhibiting chronic opioid-induced glial
reactivity using propentofylline [7] and inhib-
iting proinflammatory cytokines [8] attenu-
ate morphine-induced tolerance. Minocycline,
which inhibits microglial migration [9], attenu-
ates the development of antinociceptive tolerance
to chronic morphine through inhibition of p38
MAPK in activated microglia. These studies indi-
cate that microglial migration may play a critical
role in morphine tolerance as has been shown in
neuropathic pain states. We recently discovered
that morphine enhances microglial Iba-1 expres-
sion [RJ Horvath, unpublished data] and migra-
tion towards ADP in a µ opioid receptor-depend-
ent manner. We propose that chronic opioid
administration induces microglial reactivity and
migration towards the dorsal horn, which in turn
leads to increased pro-algesic factor production
and neuronal sensitisation.
Cannabinoids and
neuroimmune interactions
The cannabinoid system modulates both neu-
ronal and immune functions using at least
two protein-coupled cannabinoid receptors
(CBR), CBR1 and CBR2. CBR1 are expressed
in the brain, spinal cord, glia and peripheral
nerves and are responsible for the psychotropic
effects of cannabinoids. The acute spinal CBR1
activation induces antinociception, but also
neurological side effects, antinociceptive toler-
ance and hypersensitivity. CBR2 are expressed
peripherally in immune cells and keratinocytes.
CBR2 also exist in the CNS, mainly in astro-
cytes, microglia and perivascular cells especially
during inflammation, nerve injury and other
neuronal insults. Recently we have shown that
four days after peripheral nerve injury, CBR2
protein is expressed in microglia and perivas-
cular microglia but not in neurons or astrocytes
[5]. We demonstrated that spinal CBR2 activa-
tion, using the selective CBR2 agonist JWH-
015, induces antinociception and reduces spinal
Iba-1 and CD11b/CR3 (microglial markers) and
GFAP (astrocytic marker) expression in post-
operative and neuropathic pain models. Fur-
thermore, we have shown for the first time that
perivascular microglial cells seem to be instru-
mental in the maintenance of pain following L5
nerve transection, since JWH-015 increases the
anti-inflammatory factor ED2/CD163 in spinal
 13 – Issue N°7 – Dec. 2008 - Jan. 2009

perivascular microglia following
peripheral nerve injury.
Additionally, CBR2 reduces the
number and regulates the function
of infiltrating T-leukocytes into the
brain in rodent models of multi-
ple sclerosis. This CBR2 action is
significant since T-leukocyte and
macrophage trafficking into the
CNS following peripheral nerve
injury is instrumental for the main-
tenance of microglial activation
and pain. Our findings thus suggest
that CBR2 provide an attractive
target that may pharmacologically
act to induce a spinal microglial
anti-inflammatory phenotype.
the treatment started day five after
nerve injury; and (3) inhibited the
production of proinflammatory
cytokines such as IL-1b, IL-6 and
TNFa in the L5 lumbar spinal cord
in association with the reversal of
hyperalgaesia and allodynia [13].
We recently also showed a novel
effect of minocycline: it inhibits
microglial motility by reducing
b1 integrin expression and Kv1.3
channel activity and expression.
We propose that reducing micro-
glial trafficking to injured neurons
following nerve injury decreases
the release of proinflammatory
mediators into the synaptic milieu
and prevents neuronal sensitisa-
tion, the pathological correlate to
chronic pain.
Ibudilast is a non-selective PDE
inhibitor that decreases CNS CR3/
CD11b and GFAP expression fol-
lowing nerve injury or morphine
administration. Ibudilast has been
shown to enhance morphine anal-
gaesia while decreasing morphine
tolerance and morphine withdrawal
symptoms and thus may have clini-
cal utility as an opioid adjuvant
to decrease dose escalation and
adverse opioid side effects.
Finally, we have shown that pro-
pentofylline, an atypical methylx-
anthine has been shown to signifi-
cantly decrease neuropathic pain
behaviours and associated glial
reactivity and cytokine expres-
sion [14]. Propentofylline has been
shown to reduce proliferation and
migration [15]. The specific mech-
anism of its anti-nociceptive effects
remains unknown. However,

Novel glial modulating

drugs and targets
Currently, the total number of
specific glial modulators is quite
limited but includes a broad spec-
trum of chemical structures and
mechanisms. The role of spinal
astrocytes in nociceptive process-
ing and hyperalgesia was dem-
onstrated using fluorocitrate, a
non-selective metabolic inhibitor,
in a neuropathic pain model [10].
However, due to potential neu-
rotoxicity of fluorocitrate, its use
as a selective glial inhibitor is not
favoured. More recently, a more
selective astrocytic metabolic
inhibitor, intrathecal methionine
sulphoximine (MSO) was used
to demonstrate that an astro-
glial glutamate-glutamine shut-
tle induces central sensitisation
of nociceptive neurons following
peripheral inflammation [11].

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

propentofylline inhibits adenosine transport as

well as the cyclic-adenosine-5’,3’-monophos-
phate (cAMP)-specific phosphodiesterase (PDE
IV). We have demonstrated that propentofylline
increases cAMP levels, suppresses an activated
astrocytic phenotype, enhances a specific gluta-
mate transporter, GLT-1 and increases glutamate
uptake in vivo and in vitro [16].

Conclusions, future directions

Within minutes to hours following a periph-
eral nerve injury, spinal microglia may become
reactive by using TLR4/CD14 as the receptor
complex to sense changes in the glial/neuro-
nal milieu. This signalling leads to the release
of cytokines and growth factors from micro-
glia and promotes microglial migration and
proliferation which in turn alert astrocytes to
a perturbed synaptic milieu. Astrocytes then
produce and release specific sensitising chem-
okines like monocyte chemoattractant pro-
tein (MCP-1/CCL2) which enables T-leuko-
cytes and/or macrophage migration into the
parenchyma of the CNS. This cell migration
propagates the immune response and further
induces microglial and astrocytic immuno-
competence [Figure 1]. We have highlighted
several novel drug targets involved in glial
function and the immune response including
inhibition of glial proliferation and migra-
tion, modulation of perivascular ED2/CD163
and astrocytic glutamate transporter, GLT-1,
and interference of pro-inflammatory inter-
actions between populations of immune and
glial cells.
References
1. Cao L, DeLeo JA. Eur J Immunol 2008;
38(2):448-458.
2. Tanga FY, Nutile-McMenemy N, DeLeo JA. Proc
Natl Acad Sci U S A 2005; 102(16):5856-5861.
3. Tanga FY, Raghavendra V, DeLeo JA.
Neurochem Int 2004;45(2-3):397-407.
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
stand ZS80
F-201
COMPRESSOR NEBULIZER
www.ihe-online.com & search 44990
Figure 1. Artist’s depiction of major cellular contributors of chronic pain states and their interface with the
microvasculature: neurons, microglia, astrocytes, perivascular microglia and T-leukocytes. Potential drug
targets to modulate glial-neuronal function: 1) Inhibit microglial proliferation and migration; 2) enhance
astrocytic GLT-1 expression; 3) enhance perivascular ED-2/CD163 expression; 4) interfere with specific
neuronal-glial and/or neuronal-immune interactions.
4. Bauer J, Huitinga I, Zhao W, Lassmann H, Hickey The authors
WF, Dijkstra CD. Glia 1995; 15(4):437-446. Edgar Alfonso Romero-Sandoval, MD, Ph.D. b,c,
5. Romero-Sandoval A, Nutile-McMen- Ryan J Horvath b,c,
emy N, DeLeo JA. Anesthesiology 2008; Joyce A. DeLeo, Ph.D. a,b,c
108(4):722-734.
6. S ong P, Zhao ZQ. Neurosci Res 2001; a
Department of Pharmacology and Toxicology
39(3):281-286. Dartmouth College
7. Raghavendra V, Tanga FY, DeLeo JA. Neu- Hanover, USA
ropsychopharmacology 2004; 29(2):327-334. b
Department of Anesthesiology
8. Raghavendra V, DeLeo JA. Cytokine modula- Dartmouth-Hitchcock Medical Center
tion of opioid action. In: Schmidt, RF, Willis, Lebanon, USA
WD (Eds) Encyclopedia of Pain 2006, New c
Neuroscience Center at Dartmouth
York(Springer):227-235. Dartmouth College,
9. Nutile-McMenemy N, Elfenbein A, Deleo JA. J Hanover, USA
Neurochem 2007;103(5):2035-2046.
10. Meller ST, Dykstra C, Grzybycki D, Murphy Correspondence
S, Gebhart GF. Neuropharmacology 1994; Edgar Alfonso Romero-Sandoval, MD, Ph.D.,
33(11):1471-1478. Joyce A. DeLeo, Ph.D.,
11. Chiang CY, Wang J, Xie YF, Zhang S, Hu Departments of Anesthesiology and Pharmacology
JW, Dostrovsky JO, Sessle BJ. J Neurosci HB 7125 • One Medical Center Drive
2007;27(34):9068-9076. Lebanon, NH 03756, USA.
12. Aronson AL. J Am Vet Med Assoc 1980; 176(10 Tel: +1 603 650 6204
Spec No):1061-1068.
13. Raghavendra V, Tanga F, DeLeo JA. J Pharma- Acknowledgements
col Exp Ther 2003; 306(2):624-630. The authors acknowledge Matthew S. Alkaitis
14. Sweitzer SM, Schubert P, DeLeo JA. J Pharma- for excellent editorial assistance; Robert Lee for
col Exp Ther 2001;297(3):1210-1217. Figure 1 illustration; and NIH/NIDA DA11276.
15. Horvath RJ, Nutile-McMenemy N, Alkaitis
MS, Deleo JA. J Neurochem 2008.
Comments on this article?
16. Tawfik VL, Lacroix-Fralish ML, Bercury KK,
Feel free to post them at
Nutile-McMenemy N, Harris BT, Deleo JA.
www.ihe-online.com/comment/pain_management
Glia 2006;54(3):193-203.
 Minimally-invasive Surgery 15 – Issue N°7 – Dec. 2008 - Jan. 2009

NOTES –
scarless surgery of the future
Laparoscopy has made many procedures less invasive,
however, today it seems that this is not enough. The new-
est challenge for the medical environment is applying the
technique of scarless surgery in humans. This is achieved by
Natural Orifice Transluminal Endoscopic Surgery (NOTES),
in which access to the peritoneal cavity is achieved and
some procedures are feasible through natural orifices
such as the digestive tract, vagina or urinary bladder. If
the safety and advantages of these approaches can be
proved beyond question, NOTES procedures are likely to
be adapted in humans after overcoming critical obstacles,
such as reliable closure methods, indispensable equipment
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.
NOTES horizons
NOTES includes transgastric, transvaginal, transcolonic, transrec-
tal or transvesical access to the peritoneal cavity or even the tho-
rax. Up until now several NOTES applications in humans have been
reported, but most of the documented NOTES procedures have been
performed on animal models. On the other hand, NOTES-like pro-
cedures, such as PEG, endoscopic pancreatic pseudocyst drainage
or needle puncture of structures through the gastric wall have been
practised for years. The debridement of infected necrotic pancreatic tissue is
another example of the minimally invasive management of a life-threaten-
ing state, which can decrease postoperative morbidity and mortality. A small
series of transgastric appendectomies, fallopian tubal ligations and cholecys-
tectomies in humans has been reported. The first totally NOTES procedure
was performed by a French team from IRCAD. The initial clinical trial of a

Blood pressure monitors

by Dr Jarek Kobiela

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

Scarless surgery has now become a great

challenge for the whole medical environment. Body composition monitors

Electronic nerve stimulators

The latest initiative in this new era of medicine is NOTES. This interdis-
ciplinary field of study consolidates endoscopists of different specialties
such as gastroenterologists, urologists or gynaecologists, with sur- Nebulisers
geons and scientific innovators, in the common effort to prove that
transluminal endoscopic surgery by natural orifices should achieve a
place in the field of minimally invasive procedures. The first successful
natural orifice surgery carried out was transvaginal nephrectomy in a
porcine model; this was performed in 2002 by Gettman et al [3]. Sub-
www.omron-healthcare.com
sequently, multiple diagnostic and experimental animal studies have
been reported.
www.ihe-online.com & search 44807
 – Issue N°7 – Dec. 2008 - Jan. 2009
Figure. 1. Transvaginal surgery.
peritoneoscopy in human subjects showed that
despite some variability in the findings during
laparoscopic and endoscopic exploration, trans-
gastric access for this procedure is feasible and
encouraging.Another report of transvesical perito-
neoscopy also demonstrates a promising outcome
and is considered to be even better than transgas-
tric procedures. Nonetheless, further investigation
is necessary in order to demonstrate that both
these methods are safe and truly advantageous for
the patient.
A great deal of progress has been achieved in
porcine model experimental studies. Several
survival and non-survival studies with pigs
undergoing transgastric or transvaginal chole-
cystectomy have been reported. The stomach
incision was performed by a needle-knife, fol-
lowed by a guidewire, which was introduced
into the peritoneal cavity. After removal of
the gall bladder, endoscopic suturing was per-
formed. The closure of the stomach wall was
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
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SCALE
www.ihe-online.com & search 44996
16 Minimally-invasive Surgery
accomplished with two to four stitches. In other
studies, the abdominal cavity was reached by
The surgical application
that could revolutionise the
position of NOTES globally
could be cholecystectomy.
incision of the anterior vaginal wall after vagi-
nal antibiotic lavage. A complete abdominal
exploration was then performed. The gall blad-
der was dissected from the liver using differ-
ent types of endoscopic forceps and a needle-
knife. The cystic duct and artery were ligated
with endoclips. Sutures were used to close the
incision. Other promising animal studies are
transgastric fallopian tube ligation, transgastric
splenectomy and peritoneoscopy. These studies
demonstrate the feasibility of such access to the
peritoneal cavity in an animal model.
ICU staff believe that endoscopic access to
enable abdominal exploration would allow this
procedure to be performed at the bedside, with-
out complicated and dangerous transport of the
ICU patient. A series of autopsies shows that
50% of undiagnosed comorbid medical con-
ditions in the abdomen of ICU patients could
have been corrected; this would probably have
increased the chance of those patients’ survival.
An attempt to apply this method to human sur-
gery has been made, but only with laparoscopic
visualisation [31]. Nonetheless, this is a specific
bridge to performing NOTES in humans.
Transvaginal and transgastric approaches were
also applied to nephrectomy [9,32]. The out-
come of these methods is very encouraging.
Kidney resection was successful and no clinical
signs of infection were noticed. Transvaginal
access seemed to be better because it did not
require endoscopic closure, however, the limi-
tations incurred by the porcine anatomy made
the procedure cumbersome and, in a few cases,
the use of an abdominal trocar was required to
facilitate visualisation.
A NOTES-like technique was used for retro-
peritoneal adrenal and renal surgery. A flexible
endoscope was introduced to the desired field
by percutaneus incision. Procedures such as ret-
roperitoneoscopy, adrenalectomy, renal biopsy
and resection were performed in the porcine
model. It was concluded that this access is fea-
sible and available but that new and adequate
instruments are indispensable.
Apart from the application of NOTES for
abdominal surgery, the use of natural orifices
as an access to the thorax has been considered.
Transvesical and transdiaphragmatic thoracos-
copy with a lung biopsy was introduced. Fur-
thermore, thoracic sympatectomy and phrenic
nerve pacing electrode implantation are other
potential applications of such an approach.
NOTES: the advantages
To summarise, what actually are the essential
advantages of NOTES that encourage special-
ists from the different fields of science and from
many countries in the world to resolve the diffi-
culties related to this crucial method? The range
of benefits depends on whose opinion is being
sought. NOTES access does not need to be better,
more convenient or optimal to be preferred by the
patient, who will be really satisfied if there are no
scars and if recovery is fast [2, 34]. The positive cos-
metic effect is very important and when a NOTES
technique is used, this will always be superior to
laparoscopic and open surgery. Another advan-
tage of minimally invasive procedures is reduced
surgical trauma (IL-1, IL-6, TNFa levels) [35],
and an undeniable advantage is the reduction of
pain caused by the surgery, as the visceral wall has
many fewer terminal nerve endings, which are
responsible for feeling pain, than skin, fascia and
muscles [14]. Obese patients, for example, who
have incisions after laparoscopic bariatric surgery
suffer from pain on coughing; this makes these
patients restrain this reflex, which increases the
risk of postoperative lung complications [2]. In
addition, one can anticipate that there will be a
reduction of MRSA and other hospital infections
if there are fewer skin incisions [2]. Of course, the
fact that NOTES can be performed without leav-
ing scars is also beneficial for surgeons, because it
makes their patients happier and in many cases
more satisfied with the procedure [34].
The general advantage of the development of
NOTES is also the competition the technique gen-
erates, which can facilitate improved laparoscopic
and endoscopic surgery by encouraging specialists

to improve their skills [2]. Even if this technique
does not prove to be as safe and useful as it
appears, some surgical fields will benefit from the
research efforts put into developing the technique
and advances will be made enabling the inven-
tion of phenomenal, modern equipment such as
thinner, more effective flexible endoscopes.
Challenges
- optimal technique for peritoneal access
- gastric closure (risk of a leak); sutures, clips
or endoscopic stapler
- risk of peritoneal infection, abscess after
puncturing gastric wall
- spatial orientation (retroflexed endoscope)
- team work of surgeons and
gastroenterologists
- physiology of pneumoperitoneum (carbon
dioxide?), intraperitoneal pressure control
- training
The surgical application that could revo-
lutionise the position of NOTES globally
are cholecystectomy, and possibly bariatric
procedures and fallopian tubal ligation [2, 36]. If
the new methods and procedures can be proved
to be safe and effective, they may provide a new
dimension to minimally invasive surgery [36].
NOSCAR announces 2008 NOTES Research
Award winners
The Natural Orifice Surgery Consortium
for Assessment and Research (NOSCAR),
a joint effort of the American Society for
Gastrointestinal Endoscopy (ASGE) and
the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES), has
announced the 2008 NOSCAR Research
Award winners. The funds, granted
through Olympus Medical Systems’
Olympus Research Fund and by KARL
STORZ Endoscopy-America, Inc., will
be distributed among 14 grant recipients
supporting 16 research projects in the
emerging transdisciplinary therapy known
as Natural Orifice Translumenal Endoscopic
Surgery (NOTES), an approach that could
ultimately represent a major paradigm shift
in minimally invasive therapy and patient
care. NOSCAR received 32 grant applications
for the $750,000 in research funds.
The first NOSCAR Research Awards were
announced in 2006. Since that time, 56
grants have been awarded. Recipients of
the 2008 awards are conducting research
in both animal models and humans.
Past NOSCAR Research Award winners
recently presented data from their projects
at the 3rd International Conference on
NOTES held in San Francisco, CA, USA,
17
What is certain is that for some aspects, such as
cosmetic effects or post-operative pain, trans-
luminal procedures will always be superior to
classic open surgery or even to laparoscopic
methods. However, some features of NOTES
are not yet considered to be as beneficial for
the patient as laparoscopic techniques [2].
Summary
Laparoscopy has brought enormous changes to
traditional open techniques, however, translu-
minal endoscopic surgery will gain its own place
in the field of surgery in the near future. The
rapid development of the NOTES technique is a
necessity, considering the advantages that it can
bring. The possibility of performing truly scar-
less, safe, more effective and , at the same time,
less painful and minimally invasive surgery is
very tempting for doctors. What is actually more
important, is that the benefits for patients will
encourage the medical world to make every
effort to realise the potential of NOTES.
References
1. Valdivieso E, Saenz R, Claudio N. Natu-
ral orifice transluminal endoscopic sur-
gery: putting together minimally invasive
July 10-12, 2008. Presentations included
research on improving patient safety and
multidisciplinary team efficiency, the
physiological and immunological impact of
NOTES, drainage of abdominal abscess and
gastric leak testing, among others.
Awards Supported by Olympus Medical
Systems included:
- Juliane Bingener-Casey, MD, Mayo Clinic,
Rochester, MN
Randomised Double-Blinded Trial
Comparing Laparoscopy and Natural
Orifice Translumenal Endoscopic Surgery
Procedures in a Porcine Model
- B. Joseph Elmunzer, MD, University of
Michigan, Ann Arbor, MI
Endoscopic Full Thickness Resection of
Gastric Lesions Using a Novel Grasp-and-
Snare Technique: Evaluation in a Porcine
Survival Model
- Michael Marohn, DO, Johns Hopkins
University School of Medicine, Baltimore,
MD
Immune & Baseline Alterations on the
Physiologic Response to Natural Orifice
Translumenal Endoscopic Surgery (NOTES):
A Comparison Between Human Transvaginal
and Laparoscopic Cholecystectomy.
– Issue N°7 – Dec. 2008 - Jan. 2009
techniques for new era. Gastrointestinal
Endoscopy 2007;66:340-342.
2. Swain P. A justification for NOTES – nat-
ural orifice translumenal endosurgery.
Gastrointest Endosc 2007; 65(3):514-516.
3. G ettman MT, Lotan Y, Napper CA, et al.
Transvaginal laparoscopic nephrectomy:
development and feasibility in the por-
cine model Urology 2002; 59(3):446-450.
4. Wallace MB. Take NOTES (Natural Ori-
fice Transluminal Endoscopic Surgery).
Gastroenterology 2006; 131:11-12.
5. Columbia physicians perform first US
transvaginal cholecystectomy. Available
at: www.columbiasurgery.org/news/si/
index.html [Accessed June 4, 2007].
6. European Association for Transluminal
Surgery, http://www.eats.fr
7. Kalloo AN, Singh VK, Jagannath SB,
et al. Flexible transgastric peritoneos-
copy: a novel approach to diagnostic and
therapeutic interventions in the perito-
neal cavity. Gastrointest Endosc 2004;
60:114-117.
8. Schauer P, Chand B, Brethauer S. New appli-
cations for endoscopy: the emerging field
of endoluminal and transgastric bariatric
surgery. Endosc Surg 2007; 21: 347-356.
The author
Jarek Kobiela M.D.,
Department of General, Endocrine
and Transplant Surgery
Medical University of Gdansk,
Poland
7 Debinki Str.,
PL-80-211 Gdansk, Poland.
e-mail: kobiela@amg.gda.pl
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/Notes
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
stand ZS80
LA-6440
LARYNGEAL MASKS
www.ihe-online.com & search 44995
 – Issue N°7 – Dec. 2008 - Jan. 2009 18 Telenursing

Ethical issues in telenursing

Telenursing in healthcare brings advan-
tages for both patients and person-
nel: for example, the improvement of
resource- and time allocation and access
for patients. However, this technique
might also entail ethical difficulties. In
this article a range of ethical aspects
that are particularly challenging in
telenursing are discussed.
by Dr Anna T. Höglund &
Dr Inger Holmström
Efficient telephone advice nursing is one way of
managing limited resources in healthcare. It is cost
efficient, timesaving and increases patients’ ability
to self-care [1]. In many Western countries telen-
ursing is an expanding part of healthcare. Telen-
ursing work is complex and knowledge-intensive.
The nurses should be able to work independ-
ently, make decisions about the caller’s need for
further care, give advice on self-care or refer the
caller to the appropriate source of help [2]. When
telenurses triage callers’ conditions, their assess-
ments are based on verbal communication. This
demands a high level of communication skills and
the ability to listen [3]. One of the major problems
for telenurses is that they cannot see the patients.
They feel considerable responsibility and they fear
making wrong decisions [4]. Furthermore, telen-
urses may percieve the contact with patients in tel-
ephone advice nursing as a conflict between being
a care provider and a gatekeeper [4].
Telephone nursing in Sweden
During the last decade, the number of call cen-
tres in Sweden has rapidly increased, as well as
the number of calls per centre. In 2003, cen-
tralisation of telenursing in Sweden started with
implementation of a national telephone helpline
as a 24-hour nurse-led telephone advice service
with one phone number for the entire country.
This system has strong similarities with NHS
Direct in the United Kingdom and Health Direct
in Western Australia. The nurses working at the
Swedish call centres sit at computer terminals,
wearing headsets, and take calls from the gen-
eral public. Most calls concern infections such
as colds, influenza or diarrhoea, and over 50%
of the calls are made on behalf of the ill person,
mostly by parents or spouse [5].
Ethics in nursing
Ethics has long been regarded as a central con-
cept in nursing. Today, teaching and training
in ethics is a well-established part of nursing
education and ethics is an accepted part of
nursing competencies. Ethics deals with ques-
tions such as how we should lead our lives and
how to relate to and behave towards other peo-
ple. Theories of moral philosophy judge actions
from their consequences (e.g. utilitarian think-
ing) or on whether they conform to ethical
duties or rules (deontological thinking).
Since the 1970s, ethical dilemmas in
healthcare(i.e., situations when norms and
values conflict and there are good reasons for
more than one course of action) have been
much discussed, and have been divided into
four well-established ethical principles: auton-
omy, non-maleficence, beneficence and jus-
tice [6]. These principles are also reflected in
the International Council of Nurses’ Code of
Ethics (www.icn.ch).
It is reasonable to argue that nursing eth-
ics shares its most important features with
other medical ethics. However, it has also been
argued that nurses deal with ethical dilemmas
in a unique way, focusing upon relations, car-
ing and communication. In more recent times,
the ethics of virtue has also been proposed as
a suitable theoretical basis for nursing eth-
ics. In virtue ethics, the character of the moral
agent is at the fore. A person is virtuous in that
s/he develops certain characteristics, such as
empathy, patience and courage.
Ethical dilemmas in telenursing
Studies have reported different kinds of ethical
dilemmas that nurses encounter in their daily
practice [7]. Likewise, increasing ethical dilem-
mas have been shown to create stress reactions
among healthcare personnel. Moral distress
can be defined as negative stress symptoms that
occur due to a situation where the healthcare
provider has identified an ethical dilemma and
assumes s/he knows the right thing to do, but
institutional constraints hinders him/her from
pursuing the desired course of action [8]. Such
moral distress has been particularly studied
among nurses.
Although telenursing brings great advantages
for both patients and personnel in the form of,
for example, resource and time allocation and
improved patient access, it might also entail
ethical difficulties. Kaplan & Litewka [9] have
identified privacy, security, confidentiality and
autonomy as ethically troubling areas in tele-
medicine in general, of which telenursing is
one branch. We argue, based on an empirical
study consisting of interviews with twelve Swed-
ish telenurses [10], that autonomy, integrity,
During the last decade, the number of call centers
for telemedicine has rapidly increased in Sweden.
prioritising, information and documentation
are ethical aspects that can be particularly chal-
lenging in telenursing. In the following section
we will discuss each of these aspects in the light
of ethical theory.
Autonomy versus beneficence
Within telenursing it is not unusual that the
caller is not the actual patient, but a close rela-
tive. It may be a parent calling on behalf of a
sick child or a wife calling for her husband.
The ethical dilemma telenurses can experience
in the latter situation is a conflict between the
patient’s autonomy and the relative’s, as well
as the nurse’s, ambition to do help the patient.
Hence, the principles of autonomy and benefi-
cence are in conflict. The nurse always strives
to speak to the patient herself, but when that is
not possible she has to walk a fine line between
help and respect. Sweden is a multicultural
society and several telenurses have experi-
enced this type of ethical conflict in relation
with cross cultural encounters. For example,
young women from so called honour related
cultures are sometimes not allowed to contact
the healthcare services by themselves, and thus
the conversation must be through a third party,
which in turn might create ethical dilemmas
for the telenurse.
Integrity and documentation
One aspect several telenurses experience as eth-
ically troubling is that the encounter over the
phone is “faceless” which makes it difficult for
the nurse to “read” the patient through body
 19 – Issue N°7 – Dec. 2008 - Jan. 2009

language and face expressions. This means
that decisions must be based only on the ver-
bal information the caller chooses to reveal.
Further, the nurse can never be fully sure of
the caller’s identity, in spite of the fact that
the caller gives a name and a social security
number. This raises the ethical question of how
to ensure the caller’s integrity within telenurs-
ing. One way to handle this dilemma is by being
restrictive about information on previous ill-
ness and calls. Furthermore, a telenurse should
be cautious when sensitive information is to be
documented, for example, when calls concern
psychiatric illness or venereology/gynaecology.
On such occasions, a telenurse may just note
‘referral’ in the record, which is a correct but
not very informative notation.
nurse describes it, this is “walking a fine line,
both ethically and as a fellow human being”
[10, p.1869].
Ethical competence building in
telenursing
As ethical dilemmas occur frequently in telen-
ursing the question of ethical competence build-
ing in this context is urgent. Nurses’ individual
qualities, as well as the organisational climate,
are important aspects to address in this discus-
sion. Ethical competence is both an individual
and an organisational responsibility in the
healthcare system. In order to be able to identify
if a dilemma is truly ethical in nature, as well as
to be able to judge and act upon it, high ethical
competence is needed among nurses.
9. Kaplan B et al. Cambridge Quarterly of
Health Care Ethics 2008;17:401-416.
10. Holmström I et al. Journal of Clinical
Nursing 2007;16,:1865-1871.
11. Kälvemark Sporrong S et al. Nursing Ethics
2007;14:825-837.
The authors
Anna T. Höglund, Ph.D., Associate Professor,
Inger Holmström, R.N., Ph.D., Associate
Professor,
Centre for Research Ethics and Bioethics,
Department of Public Health and Caring
Sciences, Uppsala University, Sweden
Anna.Hoglund@crb.uu.se
Inger.Holmstrom@pubcare.uu.se

Priority setting and the
healthcare organisation
As a telenurse can be described as being both a
healthcare adviser and a “gate-keeper”, priority
setting is part of the day-to-day work in telen-
ursing. In Sweden, priorities should be made
according to a platform consisting of three ethi-
cal principles, namely the principles of human
dignity, need and solidarity, as well as cost-effi-
ciency. This ethical platform has been adopted
by the Swedish parliament and is also inscribed
in the Swedish Health and Medical Services Act.
Priority decisions have been shown to create
several dilemmas for telenurses. They experi-
ence concerns about the healthcare organi-
sation and the fact that certain patients “fall
through the safety net” as they are constantly
referred, for example, from the GP to a psychi-
atric clinic, back to the GP, etc. In these situ-
ations the principle of cost-efficiency collides
with the principle of human dignity. Telenurses
can experience this as extremely unethical and
also develop moral distress symptoms. They
want to give care, but the organisational struc-
tures hinder them from following through on
the preferred course of action.
Responsibility and information
Ethical dilemmas in telenursing can also occur
due to the nurses’ obligation to inform the
patient and at the same time avoid giving too
much information that might overwhelm the
One way to achieve this could be to work with Comments on this article?
Feel free to post them at
so called ethics rounds, i.e., a form of institu-
tionalised, interprofessional ethics discussions www.ihe-online.com/comment/Telenursing
[11]. In addition to the increased ethical com-
petence that might come out of such ethics
rounds, a decrease in moral uncertainty and
moral distress might also follow.
FAZZINI s.r.l.
s.s. Padana Superiore 317
Conclusions 20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
The identified ethical dilemmas in telenursing Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
also occur in other forms of nursing. However, www.fazzini.it
telenursing might be particularly sensitive to
ethics. For example, respect for autonomy and
obtaining informed consent might be difficult Arab Health Dubai
stand ZS80
when a woman calls in for her spouse, respect
for integrity might be difficult in both the
information and the documentation process,
F-208
ULTRASONIC
and the balancing of giving the patient hon- PROFESSIONAL
est information with the ethical demand to NEBULIZER
avoid harm, are all examples of ethical dilem- ON TROLLEY
mas that telenurses handle in their daily work.
Hence, ethical competence building and ethi-
cal discussions on a regularly basis are needed
for telenurses.
www.ihe-online.com & search 44993
References
1. M arklund B et al. Journal of Nursign
Management 2007;15:180-7.
2. H olmström I. Nursing and Health Sciences
FAZZINI s.r.l.
2007;9:23-8. s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
3. S nooks H et al. The development of tel- Tel. ++39/02265152-1
enursing. Journal of Advanced Nursing Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
2008;61:631-40. www.fazzini.it

patient and make him/her deny the symptoms.
Here, the ethical demand of presenting honest
information to the patient might clash with the
principle of non-maleficence. An example of a
situation that may create this dilemma is when
a patient calls in for what s/he believes is a small
problem, needing only some advice on self-care,
while the nurse apprehends thatthe symptoms
described are signs of a serious illness. The tel-
enurse feels that s/he cannot confront the caller
with the truth too abruptly, but s/he must at
the same time try to make the caller realise the
severity and urgency of the symptoms. As one
4. Holmström I et al. Scandinavian Journal of Arab Health Dubai
Caring Sciences 2002;16:142-48. stand ZS80
5. Wahlberg A. Telephone Advice Nursing. Call-
ers’ perceptions, nurses’ experience of prob-
lems and basis for assessments. Karolinska
Institute, 2004.
6. B eauchamp TL et al. Principles of Biomedi-
cal Ethics. 6th edition. New York: Oxford
University Press, 2008.
7. Wolf R, Zuzelo PR. Quality Health Research
2006;16:1191-1206. F-202
8. R aines M. JONA’s Healthcare, Law, Ethics ULTRASONIC NEBULIZER
and Regulation 2000;2:29-41.
www.ihe-online.com & search 44991
 – Issue N°7 – Dec. 2008 - Jan. 2009
Managed services:
are they really cost-effective for storing,
sharing and distributing images?
When it comes to imaging infrastruc-
tures, healthcare providers are facing
numerous challenges and it is tempt-
ing to transfer responsibility of IT
activities with their associated risks
and burden to a third party. Subscrib-
ing to a managed service to store,
share and distribute healthcare images
from a hosted platform sounds like a
good alternative. But will it be more
expensive than if the organisation
does this itself? How does this relate
to increasing cost pressures in the
healthcare sector?
by Bernard Algayres
The challenges
Volume explosion
Globally, the volume of digital information is
exploding. Recent reports from the IT mar-
ket intelligence provider, IDC (March 2008)
show that the volume of digital information
produced will multiply by 10 between 2006
and 2011. Another IT advisory company,
Gartner is expecting a 69% annual capacity
growth in this period, an even higher growth
than was expected earlier.
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
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20 HEALTHCARE IT
Healthcare data follow the same trend, with the
volume of information either produced digitally
or digitalised increasing. This is particularly true
in imaging departments with several cumula-
tive phenomena contributing to growth. New
generation CT and MR machines are produc-
ing a larger number of heavier images. The vol-
ume of images per exam is therefore so large
that new tools are necessary to improve diag-
nostic efficiency. At the same time these CT
and MR technologies are more popular, and
increasingly used for diagnosis.
Retention time also impacts on volume: legal
requirements have evolved making it now
critical to be able to present images in case of
requests from the authorities.
Collaborative work
Collaboration is now the new way of working
in all industries and this is also true in health-
care: patients often receive critical care from
multiple healthcare facilities (e.g. chronic
disease treatment requiring coordination
of different specialties). As a result, patient
data may be scattered among various clinical
systems across multiple sites with no simple
access to aggregated historical records. The
lack of healthcare professionals in a number
of specialties also increases the need to easily
access patient information from any location.
Demanding healthcare professionals
Healthcare professionals are under pres-
sure: they need to provide the best care in a
reduced- cost environment. Access to the lat-
est clinical tools and optimising workflow is
therefore key. In addition to their traditional
activity of setting up IT infrastructures, hos-
pital IT professionals need to act as real busi-
ness consultants, understanding the needs of
healthcare professionals in order to find the
right solutions.
The cost impact
Long-term preservation of information is one
of the most challenging parts of the hospital IT
organisation. Healthcare organisations trying to
find the best solution for keeping data available
over a 10 to 15 year period of time often consider
investment as the main portion of their costs. A
number of studies contradict this. Gartner esti-
mates that capital costs count for less than 20%
of the Total Cost of Ownership (TCO) of a
storage solution. When dealing with an archiv-
ing infrastructure, we can even consider that
the proportion is lower, and that the costs
of maintaining information accessible dur-
ing tens of years are largely underestimated
by IT organisations.
Let us consider a classical archiving infrastruc-
ture and list the mandatory tasks required to
maintain the minimum service levels required
by users.
Hardware and software maintenance
This is provided by the technology suppliers and
usually covers problem fixing in a reactive mode
with on-site support and software updates.
Daily infrastructure monitoring
In order to make sure that the system is working
properly, daily monitoring is important.
- At the hardware infrastructure level: this
means insuring that no hardware compo-
nent such as a RAID disk or a tape library
is damaged.
- At the application level: all the processes
that run the archiving application must
be working properly, particularly manage-
ment of the database that is the kernel of
the system. This task requires a very good
knowledge of the archiving application itself.
- At the data level: it is critical to ensure data
protection through the backup or replica-
tion processes, data security through the
analysis of access logs to the data, and data
integrity. This part is key to guarantee long
term preservation.
Problem management
This covers all the tasks related to the occur-
rence of a problem, including:
1. Problem detection and identification: identi-
fication of the exact source of the problem
2. Escalation process management: having the
right supplier handling the problem with the
proper level of priority.
3. Resolution management: implementation of
the fixes by the supplier, testing and accept-
ance of the fix, and communication with the
users impacted by the problem.
4. Hardware and software update/upgrade
management: although software upgrades
may be part of a supplier maintenance
contract, the hospital IT has to manage the
process, including:
- Management of the supplier intervention
 21 – Issue N°7 – Dec. 2008 - Jan. 2009

- Management of the user information for

possible downtime
- Minimum testing and acceptance of
the upgrade

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

www.ihe-online.com & search 44957

 – Issue N°7 – Dec. 2008 - Jan. 2009
monitoring centre and before there is any
impact on users. Problem detection in an early
phase makes it possible to solve such problems
faster and more efficiently. In most cases, proac-
tive monitoring can even prevent problems
from occurring.
• 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.
FAZZINI s.r.l. - s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1 - Fax ++39/0227409242
e. mail: fazzini @ fazzini.it ~ www.fazzini.it
Arab Health Dubai
stand ZS80
SA210
PULSOXYMETER
www.ihe-online.com & search 44997
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
stand ZS80
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MOBILE SUCTION PUMP
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22 HEALTHCARE IT
Figure 2. The proactive monitoring approach.
-E
 nhanced connectivity: the solution must
interconnect through different protocols to
different applications from different vendors.
-C
 linical information lifecycle management:
this is particularly important in order to
optimise cost and ease migration.
• Organisation
Providing a managed services offer requires a
dedicated organisation, which must employ
highly skilled experts who are always available
to make sure that the system is optimised in
terms of availability, security and performance.
Advanced monitoring tools are also key in order
to ensure the quick detection of any issue, the
immediate preliminary diagnostic, and quick
involvement of the right level of expertise.
Costing evaluation
General considerations
We have seen that analysts consider that in the
Total Cost of Ownership of a classical storage
infrastructure, the investment costs are less than
20% of the total cost. This means that a $200k
infrastructure will finally cost $1M in a five year
period plus migration costs. Experience shows
that these costs are under evaluated.
Migration costs
Based on different studies across different envi-
ronments, estimation is that the cost for migra-
tion is around $5 000 per terabyte and that due
to obsolescence, 25% of the volume is moved
each year. This shows that the total obsoles-
cence costs can become a real problem. A hos-
pital, say producing 250 000 annual studies for
an equivalent of 25 Terabyte of uncompressed
data/12 Terabyte compressed, would incur
yearly migration costs of around $100 000 at
year seven, $150 000 at year 10 and $225 000 at
year 15. This excludes the volume growth for
this specific example.
Conclusion
Archive systems are complex systems that com-
bine servers, databases and a variety of storage
subsystems, often over several locations. They
must be maintained over long period of time.
Hospitals often consider managed services as a
way to offload their IT department and trans-
fer storage management tasks to a third party.
However, when looking at the cost aspects, they
are usually surprised that their real internal
costs are much higher than thought, and that
managed services are a way to save costs.
In addition, managed services reduce the risk
of system unavailability or data loss thanks to
permanent monitoring. Also, collecting infor-
mation from different sites to be stored and
preserved on a datacentre broadens access and
distribution of images as these activities can
be achieved direct from the datacentre with
enhanced security, instead of opening each
hospital site to the external world.
Rather than investing in infrastructure, health-
care is increasingly following industry trends
by subscribing to services on a pay as you go
basis with service level agreements. Carestream
Health with its eHealth Managed Services, is at
the leading edge of this movement.
The author
Bernard Algayres
General Manager
eHealth Managed Services
Carestream Health
www.carestreamhealth.com
www.ihe-online.com & search 45125
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/IT
 News in brief 23 – Issue N°7 – Dec. 2008 - Jan. 2009

Bad bosses may damage your heart

1-3 april 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

Discovery of molecular switch wins

Eppendorf/Science prize
Dr. Mauro Costa-Mat-
tioli has been awarded
the 2008 International
Grand Prize in Neuro-
biology by Eppendorf
AG and the journal Sci-
ence. He is being recog-
nised for his research JOIN THE EXPERTS IN THE HEART OF EUROPE
into memory formation
and processing. “I think
that these findings con-
stitute a fundamental
advance that holds the
www.medetel.eu
hope of not only mak-
ing animals smarter, but also, ultimately of developing new therapies for Organized by:

people with age-related memory loss or the more devastating memory

loss associated with Alzheimer’s Disease,” said Costa-Mattioli, assistant
www.ihe-online.com & search 45033
 – Issue N°7 – Dec. 2008 - Jan. 2009 24
professor in the Department of Neuroscience,
Baylor College of Medicine in Houston, Texas.
In his prize-winning essay, Costa-Mattioli
describes how he and his colleagues found a
type of molecular switch in mice that “deter-
mines” whether a long-term memory is made
from an experience. “I decided to focus my
research on eIF2-alpha since it regulates two
fundamental processes which are critical for
the formation of long-lasting memories: new
protein synthesis and the activity of a memory
repressor protein, ATF4,” he said. When the
neuron protein eIF2-alpha is activated, it sup-
presses a neuron’s production of other proteins
that allow the brain to form long-lasting mem-
ories. Costa-Mattioli investigated eIF2-alpha’s
role in the formation of long-term memories
and in long-term potentiation by studying
mice with reduced eIF2-alpha activity. These
mice appeared to have improved spatial mem-
ory - they learned to remember the location of
a hidden platform in a pool faster than nor-
mal mice did - and the synaptic connections
between their neurons lasted for longer than
those of normal mice. The grand prize winner
receives $25,000 from Eppendorf, and the win-
ner’s essay, “Switching memories ON and OFF,”
is published in the November 2008 issue of the
journal Science.
www.sciencemag.org/feature/data/prizes/eppen-
dorf/eppenprize.shtml
Diabetes treatment without jabs?
A compound found in garlic is the basis of a
potential orally-available drug candidate for
types 1 and 2 diabetes. Diabetes incidence is
increasing worldwide, and there is a continuing
need to develop effective treatments. Exisiting
treatments involve either injection with insu-
lin (primarily for sufferers of type 1 diabetes),
or treatment with drugs (for type 2 diabetes).
However, neither method is ideal, says Hiromu
Sakurai, of the Suzuka University of Medical Sci-
ence, Japan, as they involve frequent injections,
and the drugs have undesirable side-effects. In
earlier work, Sakurai’s group had shown that a
complex of vanadium and allixin, a compound
found in garlic, lowered blood glucose levels in
mouse models of both types 1 and 2 diabetes
and that the effect was maintained for type 2
News in brief
model mice given the complex orally. In its lat-
est study the team found that the orally admin-
istered complex also lowered glucose levels in
type 1 model mice, offering hope for an injec-
tion-free treatment for people with type 1 dia-
betes. The vanadyl complex of garlic-compound
allixin lowers blood glucose in diabetes mod-
els. The new study looked primarily at how the
allixin complex works. By examining the effects
of the complex on genes affected by diabetes, the
researchers found that it activates not only the
insulin signalling cascade, which regulates glu-
cose metabolism, but also an enzyme that helps
cells to absorb glucose. The researchers say that
the allixin and similar complexes could be good
candidates for treating both type 1 and type
2 diabetes. Future work, says Sakurai, will be
aimed towards clinical trials of these complexes
in human diabetes patients.
http://www.rsc.org/AboutUs/News/PressRe-
leases/2008/GarlicDiabetes.asp
MRI machines may damage
cochlear implants
Patients with cochlear implants may want
to steer clear of certain magnetic imaging
devices, such as 3T MRI machines, because
the machines can demagnetise the patient’s
implant, according to new research published
in the December 2008 issue of Otolaryngol-
ogy – Head and Neck Surgery. The study, con-
ducted by a team of German and American
researchers, tested several cochlear device mag-
nets on a 3T MRI scanner with active shielding
at a variety of angles (0º, 80º, 90º, 100º, 110º,
and 180º). The researchers discovered that dur-
ing routine use of 3T MRI machines at angles
above 80º, an unacceptable level of demagneti-
sation was reached, causing permanent damage
to devices with non-removable magnets, and
creating the potential of exposing patients to
undesirable magnetic forces. As a result of their
findings, the study authors recommend that
MRI scans on patients with cochlear implants
should be performed using a 3T MRI machine
only if a 1.5T machine is not available, and if
the benefits of the scan far outweigh the risk of
cochlear implant demagnetisation.
http://www.entnet.org/
Liver disease research investment
A new £1m clinical research facility dedicated
to tackling liver disease, the fifth most common
cause of death in the UK, opens this month at
Imperial College London. Liver disease death
rates are rising in the UK, in contrast to other
common diseases such as heart disease and can-
cer, and the new Robert Hesketh Hepatology
Clinical Research Facility aims to provide care and
develop new therapies to reverse this trend. The
unit will accommodate fifty researchers, doctors
and nurses from Imperial College London and
Imperial College Healthcare NHS Trust, work-
ing together to help liver patients. In addition to
providing the best possible care for thousands of
patients, staff at the unit aim to better understand
liver disease. All of the patients will be offered
the opportunity to take part in the unit’s clinical
research programmes and some will be able to
enrol in its clinical trials. These will address the
four main causes of liver disease – alcohol, fatty
liver disease and chronic hepatitis B and C – as
well as liver cell and bile duct cancers. Blood, liver
and DNA samples taken from patients as part
of routine care will be used to develop ways of
predicting which patients will develop the severe
complications of liver disease. Researchers at the
unit will wage a war on liver disease on a number
of fronts. They will examine why some people are
genetically predisposed to alcoholism, a condi-
tion which is responsible for 70% of chronic liver
disease. They will also be looking at the genetic
reasons why some people are more susceptible to
fatty liver disease than others, and why some of
these people will progress from fatty liver disease
to hepatitis and cirrhosis. In addition, they will
be exploring how factors such as alcohol and diet
can exacerbate viral liver disease.
http://www3.imperial.ac.uk/newsandeventspg-
grp/imperialcollege/newssummary/news_1-12-
2008-14-0-7?newsid=50894

CT colonography: 1-stop screening
for cancer and osteoporosis
New research reveals that computed tomogra-
phy (CT) colonography, also known as virtual
colonoscopy, has the potential to screen for
two diseases at once - colorectal cancer and
osteoporosis, both of which commonly affect
adults over age 50. CT colonography, an imag-
ing study performed to detect pre-cancerous
polyps in the large intestine, begins with an
abdominal CT scan, which creates cross-sec-
tional images of all structures in the abdomen
including the spine. Computer software then
arranges the CT images to create an interior
or “fly-through” view of the colon. Using the
same CT images, another software applica-
tion can create three-dimensional images of
the spine, allowing bone mineral density to be
measured. Low bone mineral density is usu-
ally associated with osteoporosis, a disease in
which bones become fragile and more likely
to break. In the study conducted at the San
Francisco Veterans Administration Hospital,
USA, the researchers evaluated the results of
35 patients who underwent CT colonogra-
phy and bone mineral density testing with
dual-energy x-ray absorptiometry (DEXA),
a standard bone density screening tool.
Patients included 30 males and five females
ranging in age from 54 to 79. The results
of the study showed excellent agreement
between the DEXA bone mineral density
scores and the data generated through the CT
colonography study.
http://www.rsna.org/media/pressreleases/pr_
target.cfm?ID=387
Age-related hearing loss
gene identified
Presbycusis, or age-related hearing loss, accounts
for 30 percent of all hearing loss. So, why do
some people lose their hearing as they get older
but other people can still hear a pin drop? The
answer may be in a study released online in the
News in brief 25
journal Human Molecular Genetics. The study
was conducted in collaboration with colleagues
at the Phoenix-based Translational Genom-
ics Research Institute (TGen), Affymetrix in
Santa Clara, California, USA, and the Univer-
sity of Antwerp, Belgium. It uncovered several
genes, but one gene stands out and is believed
to put people at risk for hearing loss as they
age. Researchers discovered a common variant
in the GRM7 gene, which the research team
believes may be associated with susceptibility
to glutamate excitotoxicity and hearing loss. It
is the overexpression of glutamate that causes
damage to the inner and outer hair cells in the
inner ear leading to age-related hearing loss. The
study participants were Caucasian, ages 53 to 67,
and the samples were collected at eight centres
in six nations throughout Europe from popu-
lation registries or audiological consultations.
The team of investigators analysed the samples
and identified genetic risks. According to the
researchers, the next step is developing a labora-
tory model to test pharmaceuticals for possible
treatment of presbycusis in the future.
http://hmg.oxfordjournals.org/papbyrecent.dtl.
New mammography technology
effective in detecting breast cancer
A study has found that positron emission
mammography (PEM), a new technique for
imaging the breast, is not affected by either
breast density or a woman’s hormonal sta-
tus, two factors that limit the effectiveness of
standard mammography and MRI at detect-
ing cancer. The ability of x-ray mammog-
raphy, a standard screening tool for breast
cancer, to detect lesions is reduced when per-
formed on dense breasts, where tissue is less
fatty and more glandular. Breast MRI is effec-
tive at detecting cancer in dense breasts and
is increasingly being used to screen women at
high risk for breast cancer. However, MRI has
a high incidence of false-positive test results
that indicate cancer is present when it is not.
Researchers believe these false positives are
due in part to hormonal changes that occur
during a woman’s menstrual cycle. Because
hormones do not have the same effect on PEM
results, the researchers believe the imaging
technique could play a significant role both
in preoperatively evaluating breast cancer
– Issue N°7 – Dec. 2008 - Jan. 2009
patients and in screening high-risk patients.
In the study, 208 patients with breast cancer
underwent PEM, an application of high-res-
olution breast positron emission tomography
(PET) in which a small amount of radioactive
material is injected into the body to measure
metabolic activity and determine the presence
of disease. The researchers used a PET unit
specially developed for the breast and small
body parts to perform the PEM exam. Of
189 malignant lesions imaged, PEM detected
176 for an overall sensitivity rate of 93 per-
cent. Fifteen percent were ductal carcinoma in
situ (DCIS), a noninvasive cancer confined to
the ducts of the breast; 85 percent were inva-
sive cancer. While breast MRI exams produce
more than 2,000 images to be interpreted,
PEM produces just 48 images that can be
correlated with a woman’s mammogram.
http://www.rsna.org/media/pressreleases/pr_
target.cfm?ID=390
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
stand ZS80
F-35
SUCTION
PUMP
ON CASTORS
www.ihe-online.com & search 44988
FAZZINI s.r.l.
s.s. Padana Superiore 317
20090 Vimodrone (MI) - ITALY
Tel. ++39/02265152-1
Fax ++39/0227409242
e. mail: fazzini @ fazzini.it
www.fazzini.it
Arab Health Dubai
stand ZS80
F-200
COMPRESSOR NEBULIZER
www.ihe-online.com & search 44989
 – Issue N°7 – Dec. 2008 - Jan. 2009
Medcorp International
Distributors Wanted
Little Sucker has become the product
of choice with nurses, respiratory
therapists, and in many hospitals in the
U.S. Little Suckers replace up to three
products with just one Little Sucker.
Our three sizes, Preemie, Standard,
and Nasal Tip, are ideal for oral and
nasal suctioning in the nursery (labor
and delivery), neonatal intensive care,
pediatric intensive care, and emergency
departments. Please contact us for
samples and pricing.
Dave Berberian
Medcorp International, Dept. CN
25612 Stratford Place
Laguna Hills, CA 92653 USA
MED
12179
TEL: 949-582-0313
FAX: 949-582-3747
Medcorpint@cox.net
www. Neotechproducts.com
www.ihe-online.com & search 44753
Arab Health Dubai
stand ZS80
www.ihe-online.com & search 44987
HAVE YOU RENEWED YOUR
FREE SUBSCRIPTION ?
www.ihe-online.com
26 On show at Arab Health
Illumination solution for
the OP area
The compact Aurinio 120 light, with its three
wings, satisfies the highest functional and
hygienic demands. Due to its small size and
reduced, flat and flow-favourable design, it
only has a minimal impact on the laminar
air flow - especially important for operating
theatres. Paired with modern LED technology,
this results in even further advantages: the
Aurinio exclusively emits cold, infrared-free
light, which suppresses tissue dehydration in
the patients. Connected with its exact colour
reproduction, this produces optimum work-
ing conditions for surgeons. Furthermore,
the employed power LEDs are extremely
low-maintenance, reliable and have much
longer service lives than other lights, with
an extremely high luminous efficacy of up to
50 lumen per watt.
Trilux GmbH & Co. KG
Arnsberg, Germany
Arab Health stand ZA29
www.ihe-online.com & search 45108
Innovative operating theatre
equipment
The QA3 Variable Height Patient Trolley
series, which includes a hydraulic lift mecha-
nism, fixed telescopic transfusion pole and
foot-operated advanced braking system,
is used in more than 90 percent of hospi-
tals across the UK. The lightweight yet rigid
construction means the trolley is used both
for patient transport in theatre and casualty
areas, and also for examinations, intubations
and radiography.
Anetic Aid
Guiseley, West Yorkshire, UK
Arab Health stand 7A11
www.ihe-online.com & search 45109
Fast and effective drug testing
The Dräger DrugTest 5000 is capable of detect-
ing even minute traces of addictive drugs in
saliva within minutes. This means the test can
provide a quick check on whether a patient
has consumed drugs of abuse and to which
class they belong, making it particularly useful
prior to admission to the emergency ward. As
a preliminary test, the DrugTest 5000 analy-
ses the samples for traces of opiates, cocaine,
cannabinoids and amphetamines, as well as
designer drugs and sedatives from the group
of benzodiazepines. The results for five of the
drug classes are available after just five min-
utes, while the test for cannabinoids is com-
pleted after ten. This not only makes it possible
to exclude drug abuse quickly, it also helps to
reduce the number of cost- and time-intensive
laboratory blood tests. The system comprises
two main components: the Dräger DrugTest
5000 Analyser and the Dräger DrugTest 5000
Test Kit. After the protective cap has been
removed from the saliva test collector, a sam-
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
blue. The operator then places the test cassette
into the analyser, which displays whether the
result is “positive” or “negative” for every drug
class on its colour display. Acoustic signals
support and inform the operator during the
entire procedure. Due to its simple operation,
the test is far more discreet and hygienic for
both patients and operators than urine-based
sample collection. It also minimises health
risks associated with handling body fluids.
Dräger Medical
Lübeck, Germany
Arab Health stand 2H20
www.ihe-online.com & search 45110
 On show at Arab Health 27 – Issue N°7 – Dec. 2008 - Jan. 2009

FRONT COVER PRODUCT

Total breast imaging suite

The Selenia full-field digital mammog-

raphy system uses selenium based direct
capture technology. This eliminates light
diffusion completely for perfect clarity
and exceptional image quality. The system
incorporates the patented HTC grid tech-
nology that reduces radiation scatter for
better contrast and features a 24x29 cm
detector which will accommodate almost
all patients with a single image per view.
Hologic
Bedford, MA, USA
Arab Health stand CA60
www.ihe-online.com & search 45124

Cardiopulmonary excercise system www.ihe-online.com & search 44653

The ZAN 600 is the first and only system to incor-
porate the largest equation set ever created for cardi-
opulmonary exercise testing. This unparalleled pre- See us at Arab Health
dicted compilation is ideal for every level of exercise Stand 8B31
intensity and perfect for sub-maximum and peak
performance testing. The new system uses propri-
etary VIP (Variable Impedance Pneumotachom-
eter) sensor technology, which dynamically alters
its characteristics in real time during testing, main-
taining optimum performance by actually lowering resistance as ventilation
increases. This makes it easier for the patient to reach the desired levels of
exercise intensity for improved diagnosis and evaluation of fitness.

Medset Medizintechnik GmbH

Hamburg, Germany
Arab Health stand ZC20
www.ihe-online.com & search 45123

Data consolidation from disparate systems

into a single point of storage
The leading enterprise imaging infrastruc-
ture solution from Agfa, the IMPAX Data
Center, provides large-scale multimedia stor-
age for all types of medical images and diag-
nostic results for hospital groups, regional
healthcare organisations and national medi-
cal archives. The solution consolidates the data from disparate systems into a
single point of storage to serve the needs of the enterprise. The new Data Center
is a highly scalable and fault-tolerant DICOM archive system designed to store
clinical DICOM data objects, including DICOM-encapsulated non-imaging
objects such as waveforms, structured reports and PDFs. Healthcare provid-
ers are able to easily access various data sources within the hospital or regional
enterprise through one mechanism served by the IMPAX Data Center. The
solution delivers clear patient management benefits since exams and results are
available at every location. The system is designed to meet the needs of new tech-
nologies such as multi-sliceCT and allows for the extension of PACS into other
image-intensive clinical departments, such as cardiology and orthpaedics.

Agfa Healthcare
Mortsel, Belgium
Arab Health stand 4E30
www.ihe-online.com & search 45122
www.ihe-online.com & search 44813
www.ihe-online.com & search 45036
 On show at Arab Health 29 – Issue N°7 – Dec. 2008 - Jan. 2009

via a field generator.

FRONT COVER PRODUCT These data are trans-
ferred in real time to
Combination physiotherapy system the iGuide CAPPA
system which shows
TheStatUSTMultrasoundtreat- the position of the
ment is the latest development needle tip on a moni-
in therapy and treatment com- tor and superimposes
fort. StatUSTM stands for Sta- on the previously
tionary Ultra Sound:i.e. ultra- generated three-
sound applied without moving dimensional data set
the treatment head. Normally, of the anatomy. This
ultrasound energy is applied by provides the physician with both the necessary anatomical information as
moving the treatment head (the dynamic or semi-stationary method). well as the exact position of the needle, so the needle procedure can be safely
The movement is necessary because within an ultrasound bundle, as performed. This method is especially suitable for lengthy and complex
well as in the tissue, certain symptoms may occur which could lead interventions and the required radiation dose is greatly reduced.
to tissue damage in the form of hotspots. For this reason, treatment
with a stationary treatment head is rarely applied. The therapy how- Siemens AG
ever, is a new treatment method that transforms the disadvantages of Erlangen, Germany
static ultrasound application into advantages for both the therapist Arab Health stand 3A20
and the patient. www.ihe-online.com & search 45119

Enraf-Nonius B.V.
Rotterdam, The Netherlands
Arab Health stand 3E29
www.ihe-online.com & search 45120

Central monitoring system

The CNS-9601K cen-
tral monitor has almost
the same operation as the
patient monitor. Most func-
tions can be performed in
just three steps so busy staff
can spend the majority of
their time on patient care.
A newly added Alarm Event
window can help reduce
false alarms and provide
high quality patient care.
An optional alarm indica-
tor clearly shows the alarms
from a distance. The system
provides time-synchronised data review. All review screens are time-syn-
chronised so that when the user finds an alarm or arrhythmia episode,
he/she can see the same event on other review screens as full disclosure,
trend or numeric data.

Nihon Kohden
Tokyo, Japan
Arab Health stand 5D39
www.ihe-online.com & search 45118

GPS for interventional radiology

iGuide CAPPA is a new solution to help the physician during minimally
invasive needle procedures. The method uses electromagnetic tracking
and facilitates interventions such as precise and quick needle placements –
for liver biopsies, for vertebroplasties when stabilising fractured vertebrae,
or for cancer pain treatment. The principle is a simple one: prior to insert-
ing the needle, the Artis zee C-arm generates a 3D soft tissue image of the
anatomy to be treated, which is used for orientation by the physician. A
sensor in the tip of the needle is tracked in an electromagnetic field created
www.ihe-online.com & search 44626
 – Issue N°7 – Dec. 2008 - Jan. 2009 30 On show at Arab Health

Management of cardiological stress tests

PGSTRESS has been FRONT COVER PRODUCT
designed to monitor, store
and analyse the ECG sig- EcoAnaesthesia mask reduces number of sizes needed
nal, during the perform-
ance of provocative car- The EcoAnaesthesia mask is
diovascular tests. The 12 a single use anatomical face
ECG leads are transmitted mask with a soft, comfort-
to the PC by the MY ECG able airtight seal.The unique
BOX USB acquisition unit, design of the soft seal provides
a handheld electrocardio- a comfortable yet airtight fit,
graph applied to the patient through a standard 10-wire cable. The software which means only four sizes
controls and monitors the operation of any bicycle and/or treadmill ergom- are needed to fit the major-
eter connected, displays the ECG and the measurements made through a ity of patient face shapes,
high-resolution monitor and manages a laser printer in deferred time. whilst the lower mask vol-
ume results in reduced dead
Progetti space. Each mask is delicately
Moncalieri, Italy scented to provide the patient
Arab Health stand AZ29 with a pleasant aroma as the
www.ihe-online.com & search 45116 mask is positioned on the
face; the innovative colour-
coding system facilitates ease
Portable spirometer of use with other Intersurgical
Three different models of the airway products. The EcoAn-
small poratable spirometer aesthesia Mask is PVC- free pro-
exist, tailored to the needs of the viding a lower environmental
user. The equipment has differ- impact option.
ent configurations for use both
in clinical mode and at home. Intersurgical
Its connectivity capabilities Wokingham, Berkshire, UK
consist of a USB port for con- Arab Heath stand 7B20
nection to a PC or an external www.ihe-online.com & search 45114
printer. It can also be connected to other devices via Bluetooth technolo-
gies. The spirometer operates with a large number of parameters related to
FVC, VC and MVV, and has a pulsioximetry (SpO2) option. It has acoustic Compact lifesaver
incentives for children and a data base of up to 1000 tests. Finally, two of Cardiohelp is not only the world’s most
the models are fitted with graphic touch screens (PDA type), making them compact and lightweight heart-lung sup-
easy to use and among the most advanced spirometers on the market. port system, it is also a complete solution
for use in intensive care, cardiac surgery,
SIBEL S.A. cardiology and emergency medicine. The
Barcelona, Spain individual operating modes and the dis-
Arab Health stand 8C37 posables make the heart-lung support sys-
www.ihe-online.com & search 45115 tem suitable for all indications with cardiac
or pulmonary support, so it can be used
not only in the operating room but also in
catheter labs and especially the intensive
care units. Thus, the principle of extracor-
poreal circulation for supplying the heart
and/or lungs with oxygen is now available
in new areas as a means of life support and saving lives. Cardiohelp is
almost instantly ready to use. Furthermore, it is designed with user-
friendliness in mind, so a single push-and-turn knob and a touch screen
are all that nursing staff are required to operate. USB and Ethernet ports
mean that the system is equipped for data exchange. The unit can either
be connected up to a wall power outlet or to the electrical system on
aircraft or helicopters. Integral lithium-ion batteries provide 90 minutes
of independent operation, which is particularly important for inter- and
intra hospital transportation. The universal holder mount allows the
machine to be securely fixed to all conventional carrier systems.

Maquet
Solna, Sweden
Arab Health stand 3C10
www.ihe-online.com & search 45117
www.ihe-online.com & search 44946
 On show at Arab Health 31 – Issue N°7 – Dec. 2008 - Jan. 2009

Respiratory drug delivery

MicroElite, the new palm-sized
nebuliser compressor system,
provides speed, coupled with
total portability, to deliver fast
and effective treatments of most
commonly nebulised aerosol
medications. Combining proven
jet nebuliser technology, a fast-
charging lithium polymer bat-
tery, DC car adaptor as well as a
universal AC adapter, the port-
able system can be used almost
anywhere to give patients better piece of mind and help improve
patient compliance.

Philips Healthcare
Eindhoven, The Netherlands
Arab Health stand 3G20
www.ihe-online.com & search 45111
www.ihe-online.com & search 45037

Improved wound healing

The WoundASSIST TNP See us at Arab Health
system has been developed BOOTH N. 6B39
with the needs of the clini-
cian, patient and health-
care provider in mind.
Whether in hospital, nurs-
ing home, or community
care, the same hardware
and disposables can be
used without any compro-
mise in performance. TNP
therapy promotes an optimum wound environment, assisting in the rate
of wound closure and managing wound exudate and odour. Portable and
easy to use for patients who are mobile, the system enables discrete and
comfortable use so therapy can continue in harmony with other activi-
ties of life. Opportunities for extended times between dressing changes
result in reduced disruption to daily routine and activities.

ArjoHuntleigh International Ltd

Luton, UK
Arab Health stand 3C10
www.ihe-online.com & search 45112

New vital signs monitor

The advantages of the
CARESCAPE V100 vital signs
monitor are the extremely
short measuring times, ensur-
ing additional cost savings
and increased patient com-
fort. Given its high degree of
mobility and versatility, the
new monitor is suitable both
for ongoing monitoring and the routine measurement of vital signs in
sub-acute clinical settings.

GE Healthcare
Chalfont St Giles, Bucks, UK
Arab Health stand 4D20
www.ihe-online.com & search 45113
www.ihe-online.com & search 44684
 – Issue N°7 – Dec. 2008 - Jan. 2009
Portable digital clinical assistant
The MICA-101 is a
fanless clinical assist-
ant system incorpo-
rating a 1.1/1.6 GHz
Intel Atom Proces-
sor. The new device
provides an optimal
balance between high
performance and very
low noise — perfect
for bedside care and
clinical environments. The Intel Atom proces-
sor, with ultra low power consumption, extends
battery operating time to five hours and so helps
clinicians provide continuous, quality patient
care. The 10.4” display, with Intel Integrated 3D
Graphics, utilises a passive resistive and active
digitiser touchscreen and fully supports hand-
writing via a stylus pen. Storage needs are met by
a hard disk drive DD of 60 GB capacity. Storage
www.ihe-online.com & search 45039
Arab Health Dubai
stand ZS80
www.ihe-online.com & search 44992
32 PRODUCT NEWS
can be made even more durable by upgrading to
a solid-state drive (SSD), which adds total pro-
tection from accidential shock and bumps. The
MICA-101 is rugged, portable and lightweight,
with an ergonomic carry handle allowing medi-
cal professionals to carry it easily throughout
an entire shift. Its resistance to spills and drips
has earned it Ingress Protection (IP54) certifica-
tion. For aseptic practice, it can be wiped clean
with disinfectant.
Advantech Europe GmbH
München, Germany load to the desired level. The EC-12S provides
www.ihe-online.com & search 45132 continuous evaluation through high precision
ST and rhythm analysis and by the automatic
monitoring of HR, BP, MET and other trends.
Low power electrosurgical unit Interpretation of the results — available both
with monopolar/bipolar modes on screen and on print-out — is facilitated
by colour-coded graphs and tables. The user-
friendly product is small, light, battery operated
and has Bluetooth connection capabilities.
Labtech Ltd
Debrecen, Hungary
www.ihe-online.com & search 45133
Helping hand for stroke patients
The 970B electrosurgical unit is a low power
electrosurgical unit designed to offer the high-
est performance, both in terms of use and
safety, by including a microprocessor for the
control of all functions. The system features
an optical and acoustic display of the current
being generated. Very simple to use and thus
suitable for quick operations, the systems are
particularly useful units for the interventions
frequently carried out in specialities such
as dermatology, stomatology, gynaecology
and ophthalmology.
ST-Electromedicina, s.a.
Barcelona, Spain
www.ihe-online.com & search 45134
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
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

therapy. A combination of the HandTutor pro-
gram with traditional hand therapy produces
significant improvements in the performance
of everyday tasks.
MediTouch,
Netanya, Israel
www.ihe-online.com & search 45135
DICOM images outside the
radiology department
Medical imaging specialist Barco has introduced
a new family of clinical review displays. The
new product line is the company’s answer to the
growing demand for visualising DICOM-com-
pliant images and patient information beyond
the radiology department. The ‘MDRC’, as the
new product range is called, will provide a qual-
ity yet budget-friendly visualisation solution for
a wide spectrum of applications throughout
hospitals, imaging centres and private practices.
The MDRC displays are particularly suitable for
visualising PACS, cardiac, orthopaedic, dental or
pathology content, along with data from EMR,
HIS or RIS applications. The MDRC series
comes in two variants: a 20-inch colour screen
with 2 MegaPixel resolution and a 19-inch
colour version with 1 MegaPixel resolution.
The latter can optionally be fitted with a touch
screen interface. Both models are equipped with
professional-quality LCDs that present medi-
cal images with higher contrast and a wider
viewing angle than conventional LCD screens.
An integrated DICOM part 14 Look-Up Table
assures accurate grayscales and worry-free
‘DICOM-out-of-the-box’ imaging.
Barco
Kortrijk, Belgium
www.ihe-online.com & search 45130
New lightweight radiation-blocking
medical garments
Providing total protection in a lightweight,
durable, flexible fabric, the proprietary Demron
M product from Radiation Shield Technolo-
gies is based on the use of an advanced radio-
paque, nano-polymeric compound. This is fused
between layers of fabric and then manufactured
PRODUCT NEWS 33 – Issue N°7 – Dec. 2008 - Jan. 2009
into medical garments that provide total radiation
protection. Made of Nanoparticle-based “liquid “
metal, the material is cool, lightweight and flex-
ible. In addition the material is also environment-
friendly and, being lead and toxin-free, it may be
washed, discarded or recycled. Demron-M thus
offers a significant cost-effective alternative to tra-
ditional lead garments, which are heavy, inflexible
and prone to cracking. Demron is comfortable
and washable, and has no disposal restrictions. Its
flexibility allows for unique designs and a broad
spectrum of uses. According to independent com-
parative studies, Demron is the most lightweight
material available for X-ray shielding.
Radiation Shield Technologies www.ihe-online.com & search 44932
Miami, FL, USA
www.ihe-online.com & search 45131
Non-toxic detergent disinfectant
A cost effective solu-
tion for hospital clean-
ing with proven effi-
cacy against MRSA,
Clostridium difficile,
Noro Virus, Avian Flu,
SARS, Hep B, Hep C
and TB, Activ8 is the
first non-toxic, deter-
gent disinfectant. The
product is effective in
breaking pathogen RNA and the DNA, thus pre-
venting the replication of these organisms, and
has a 24 hour residual effect. It is also non-flam-
mable, non-irritant, environmentally friendly
and completely harmless to humans.
Available in 500L containers and 500mL trig-
ger bottles for hard surface cleaning, and in tubs
that dispense wet wipes primarily for use in high
contamination areas such as hands, keyboards,
telephones and door handles, the product is free
from odour.
Greenbridge Environmental
Control Limited
Bristol, UK
www.ihe-online.com & search 45136
www.ihe-online.com & search 44848
 – Issue N°7 – Dec. 2008 - Jan. 2009 34

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

March 12-15, 2009 June 6-9, 2009

www.ihe-online.com & search 44816
KIMES 2009 - 25th Korea Euroanaesthesia 2009
International Medical & Milan, Italy
Hospital Equipment Show Tel. +32 2 743 3290
Coex, Seoul, Korea Fax +32 2 743 3298
Tel. +82 2 551 0102 e-mail: registration@
Fax +82 2 551 0103 euroanesthesia.org
e-mail: kimes@kimes.kr www.euroanesthesia.org
www.kimes.kr
June 8-10, 2009
March 24-27, 2009 UKRC 2009
ISICEM - 29th Inter- Manchester, UK
national Symposium Tel. +44 20 7307 1410
on Intensive Care and Fax +44 20 7307 1414
Emergency Medicine e-mail:
Brussels, Belgium conference@ukrc.org.uk
Tel. +32 2 55 3631 www.ukrc.org.uk
Fax +32 2 555 4555
e-mail: sympicu@ulb.ac.be June 23 - 27, 2009
www.intensive.org CARS 2009 - Computer
Assisted Radiology and
April 1-3, 2009 Surgery 23rd Interna-
13th SE Asian Healthcare tional Congress and
& Pharma Show 2009 Exhibition
Kuala Lumpur, Malaysia Berlin, Germany
www.ihe-online.com & search 45025 Tel. +45 62 21 79 12 Tel. +49 7742 922 434

New!
Fax +45 62 20 23 37 Fax +49 7742 922 438
e-mail: bhullar@abcex.com e-mail: office@cars-int.org
www.abcex.com www.cars-int.org

April 1-3, 2009 September 16-18, 2009

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