Switzerland to adopt DRGs system - European Hospital

EUROPEAN HOSPITAL

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Smile please, nurse!UK – Following a 6-month inquiry in 2007on how to improve the National HealthService (NHS) (and patients’ organisationsurging action over an apparent decline innursing care since the domination of thehospital matron was curtailed) one of theproposals put in a Downing Street Cabinetmeeting was that doctors and nursesshould smile more.

Now a pioneering pilot training schemeis underway in Stockport Hospital, GreaterManchester, which aims to put smiles onnurses’ faces when working with patients –and more. Under a new edict, nurses are tobe banned from discussing personal mat-ters, except during breaks, or to speak loud-ly during night shifts. Another point: Neverpromise a patient ‘I’ll be back in a minute’if you cannot return do that.

The Patients’ Association (PA) reportedthat patients felt nurses had lost the ‘caringtouch’. Many, for example, claimed to be‘too busy’ to properly feed the elderly,resulting in malnutrition, whilst othersrefused to take on cleaning tasks.

However, the reaction of the RoyalCollege of Nursing was that it is insultingto suggest that nurses do not smileenough.

Also on the side of nurses, MichaelSummers, Vice-Chair of the PA’s Board ofTrustees, pointed out that they now workunder considerable pressure, so can losetouch with some patients’ needs. ‘Nursesalso qualify in primarily academic degreecourses,’ he pointed out, ‘so when theystart nursing many lack day-to-day nursingskills.’

LEGIONELLAInsurer initiates preventive

hospitals inspectionUNIQA, Austria’s leading health insur-er* recently initiated a preventiveinspection of the technical water linesand systems at around 40 of the hospi-tals it insures, to identify any possiblecontamination by Legionella bacterium.Following the inspections many of thehospitals opted to undergo TÜV certifi-cation. Their motivation is not only med-ical concern, but also economic andlegal issues.

According to the World HealthOrganisation about 10,000 people diefrom Legionnaire’s disease annually.Because an institution, rather thanwater supplier, is held responsible forthe quality of its drinking water, an out-break is not only a health risk, but haslegal repercussions.

‘The authorities are currentlyextremely active in this area. Upon sus-picion of an illness caused by Legionellacontamination, facilities are closed andcan only be opened again when it canbe verified that a risk no longer exists,’Dr Johannes Hajek, CEO of UNIQASachversicherung, pointed out. ‘For thisreason we decided to assist all hospitalsinsured through us in the fight againstLegionella by covering the inspectionand expert consultation costs.’

Following these, the hospitals canreceive a Legionellae-Free Facility TÜVcertificate.

The inspections and sharing of theexpertise were handled by HWC(Hygienic Water Consulting), a long-term partner of UNIQA in this area.

In the event of contamination, neces-sary measures are discussed and imple-mented. In almost all cases, it is possibleto get the system under control throughadaptation of the usage patterns,UNIQA reports.* In May, Uniqa Versicherungen AGannounced its intention to acquire the entireshareholding of Unita Vienna Insurance Group(transaction due for completion this autumn).With 70 companies under its umbrella inAustria and 15 in CEE countries (Germany,Poland, Switzerland, Italy, Lichtenstein,Hungary, Serbia, Bosnia and Herzegovina,Croatia, Czech Republic, Slovakian Republic,Slovenia, Ukraine and Romania), in 2005employees numbered 10,000.

Switzerland’s hospital system ishighly complicated because the 26cantons each have different regula-tions. Nonetheless, they all haveone common feature, i.e. billing iscalculated on a per diem basis,which means that medical insurerssimply pay an agreed amount perday spent in hospital – independentof a patient’s diagnosis. Any furthercosts are covered by the hospital,meaning the state or private hospi-tal operators pay.

Dr Carlo Conti, President ofSwissDRG AG, based in Basle, willorganise the switch to DRGs.‘There can be no doubt that the current billing systems inSwitzerland contain some misguid-ed incentives and are thereforecausing a conflict when it comes toachieving more efficiency for hos-pitals. The partners in the health-care sector and the world of poli-tics agree that a system change toDRGs would result in real improve-ments. National, standardised tar-iffs would also make it easier to

Switzerland to adoptDRGs system

achieve comparability and to pro-mote the exchange of healthcareservices between different geo-graphical areas within Switzerland,’he told European Hospital.

What do they hope to achieve?‘The introduction of DRG case-based lump sums is to achieve twothings: More transparency of allmedical services offered and pro-vided in a hospital and ideally a per-formance-based kind of remunera-tion. In our Federal structure, theDRGs will provide a prerequisitefor more competition between theservice providers because servicesand products delivered by hospitalscan be compared, regarding cost aswell as quality.’

Switzerland is to adopt theGerman case-based system, forexample, although this has now fall-continued on page 2

The Swiss hospitalsystem is facing a

radical change. Billingby Diagnosis Related

Groups (DRGs) is aboutto be introduced.

European Hospital’scorrespondent in

Switzerland, Dr AndréWeissen,* approachedDr Carlo Conti (above),President of SwissDRGAG to discuss some of

the controversial issuesinvolved in theswitch to DRGs

Cancer care advances– but at what cost?Half a million dollars for one extra month of lifeAlthough incremental improve-ments in cancer care were unveiledat the 44th Annual Meeting of theAmerican Society of ClinicalOncology held in Chicago, USA, –the world’s largest gathering of can-cer specialists, our correspondentIan Mason writes that, even asnew study results were beingreported, their cost implications forstretched healthcare budgets werequestioned.

Professor Robert Pirker, Med-ical University of Vienna, Austria,announced results from the FLEXstudy (Abstract #3) showing thatcombining the targeted therapycetuximab with platinum-basedchemotherapy improved overallsurvival compared to chemothera-py alone, when used as a first-linetreatment for patients withadvanced non-small cell lung can-cer – which accounts for more than80% of all lung cancers.

The addition of cetuximab boost-

ed overall survival from 10.1months to 11.3 months, a result thatProfessor Pirker described as ‘set-ting a new standard’ for the first-line treatment of this dreadfulmalignancy.

However, Professor Thomas J

Lynch, Harvard School of Medicine,pointed out that this modest sur-vival benefit – just 1.2 months –came at a cost per life year gainedof $540,000 to $622,080.

The eye-watering cost of suchinterventions underscored theimportance of pharmacogenomics –another major theme at this year’sASCO. ‘This exciting field gives us new tools to identify the mostappropriate treatment for eachpatient,’ said Dr Julie Gralow,associate professor of medicine atthe University of Washington.

In one such study, Professor Eric

Van Cutsem, University Hospital,Leuven, Belgium reported resultscontinued on page 2

2 EUROPEAN HOSPITAL Vol 17 Issue 3/08

N E W S & M A N A G E M E N T

André Weissen MD, of MedConsult (a medical consulting companybased in Riehen, Switzerland) is trained in medicine and surgery and isan internal medicine specialist and diabetologist.Dr Weissen is also a member of the Verband SchweizerFachjournalisten, and a correspondent for the Swiss Medical Tribune.Contact and details:E-address: [email protected], www.weissen.ch, www.medconsult.ch

en into disrepute. Why is it in theplan? ‘We looked at all availableoptions and came to the conclusionthat the German system best meetsour needs technically. The prob-lems in German hospitals arise fordifferent reasons,’ he explained.‘The negative effects are less to dowith the billing system, they aremore to do with the type of overallhospital financing and budgeting.’

German university hospitals areconsidered the big losers in termsof DRGs. How are all the Swisshospitals – large, small, public andprivate – to be treated in the sameway? ‘In Germany, other than in Switzerland, no investmentallowances are included in thecase-based sums. This led to aninvestment backlog in public hospi-tals,’ Dr Conti pointed out. ‘Thenew system means that all hospi-tals included on a Canton hospitallist are put on a par. This does awaywith the difference between publicand private hospitals. For the pub-lic hospitals it means the discontin-uation of the governmental deficitguarantee and equated, perfor-mance-based financing for all hos-

continued from page 1

Switzerland to adopt DRGs system

pitals. The rules of the game will bethe same for everyone, i.e. a signifi-cant improvement to the statusquo.’

Apart from the treatment costs,hospitals also have to undertakeinvestments to keep up to date andremain competitive. Is the introduc-tion of DRGs not actually counter-productive in this case? ‘I think theconnection you outline here is lessrigid,’ Dr Conti responded. ‘Theright investments will need to con-tinue in the future, enabling us toprovide our services. However, as Isaid before, other than in Germany,the investment costs are treated aschargeable costs and paid throughthe DRG case-based lump sum.This increasingly links the invest-ment to the actual amount of ser-vices provided. We hope to guardagainst a financing gap for invest-ments in this way.’

* In 2007, the Swiss Parliamentpassed the new Hospital FinancingDraft. This stipulates the introduc-tion of a national, standardised tar-iff structure (SwissDRG). TheSwissDRG is due to be introducednationwide by 1 January 2012 at thelatest.

from the CRYSTAL trial (Abstract#2) showing that patients whosetumours contain the normal form(wild-type) of the gene KRAS aremost likely to benefit from the addi-tion of cetuximab to chemotherapyas part of first-line treatment ofmetastatic colorectal cancer, com-pared to patients who have a muta-tion in the KRAS gene. He suggest-ed that KRAS testing now be rou-tinely conducted in all colorectalcancer patients immediately afterdiagnosis. This was supported byother speakers who said thatpatients with KRAS mutationsshould not be given cetuximab orpanitumumab.

In testicular cancer, results werereported (Abstract#1) showing thata single dose of carboplatinchemotherapy is as effective andless toxic than radiation therapy(the current standard of care) inpreventing recurrence after surgeryfor early-stage testicular cancer –the most common solid tumor diag-nosed in young men. ‘Personal pref-erence is becoming a more impor-tant factor in determining the besttreatment for patients with testicu-lar cancer,’ said Dr Tim Oliver, St.Bartholomew’s Hospital, London.‘This study establishes surgery fol-lowed by carboplatin chemothera-py as a safe new alternative forpatients who have early-stage semi-noma and would prefer a treatmentthat lasts a shorter period of time.’

There were also promisingresults for gynaecological malig-nancies, including results showingthat vaginal brachytherapy is aseffective as external beam radiationtherapy at preventing the recur-rence of endometrial cancer(Abstract # LBA5503). In this novelapproach, a radioactive cylinderinserted into the vagina proved aseffective at preventing the recur-rence of higher-risk endometrialcancer as external beam radiationtherapy, with fewer side effects and

a better quality of life for patients.‘Based on this study, we expect thatvaginal brachytherapy will beadopted as the new standard of carefor patients with this type ofendometrial cancer,’ said Dr Remi

Nout, Leiden University MedicalCentre.

In breast cancer, a study foundthat giving zoledronic acid (Zometa)– a drug used to treat bone metas-tases and recently approved to treatosteoporosis – to premenopausalwomen undergoing ovarian sup-pression and hormone therapy, sig-nificantly reduces the risk of recur-rence in early-stage breast cancer.‘It’s very exciting to find that in addi-tion to preventing bone loss inwomen undergoing adjuvantendocrine therapy for breast cancer,zoledronic acid can also reduce thelikelihood that breast cancer willreturn in some women,’ saidProfessor Michael Gnant, MedicalUniversity of Vienna, and Presidentof the Austrian Breast andColorectal Cancer study group(Abstract # LBA4). Another studyreported that adding bevacizumab(Avastin) to docetaxel (Taxotere)slows disease progression forpatients newly diagnosed withlocally advanced or metastaticbreast cancer (Abstract # LBA1011).

A further study (Abstract #9509)with potential cost implications forbudget holders was the finding thatmany survivors of childhood can-cers are five to ten times more like-ly than their healthy siblings todevelop heart disease in early adult-hood. The massive ChildhoodCancer Survivor Study (CCSS)showed that various types of heartdisease were two to five timesgreater in survivors who had anthra-cycline drugs (such as doxorubicin)or radiation therapy to the heart aspart of their cancer treatment, com-pared with survivors who did notundergo these treatments. * Full ASCO abstracts: www.asco.org/

Re-inventing the hospitalDuring recent years hospitals have had to face constantly new challenges. So far, thesolutions offered in Germany are not sufficient. On the contrary – rather thansolving problems, they tend to create new ones. A change of paradigm in theorganisation of hospitals is imminent and hospitals have to change radically, argueseconomist Holger Richter MA (right), Managing Director of Bremerhaven HospitalMedical servicesAbout 90% of hospital income isgenerated in the 35 weekly workinghours of regular day shifts.However, due to new work timeregulations fewer and fewerphysicians are available for theseproductive shifts and much of thework time is spent in the 133working hours of the ‘unproductive’night shifts.

Albeit, medical servicesefficiency is a crucial factor in ahospital’s survival strategy. Thismeans, in view of the shortage ofphysicians and of funds to payadditional medical staff, there isonly one solution: capacities shouldbe redefined. Medical capacitiesneed to be concentrated in thoseshifts in which most medicalservices are delivered. In turn thelevel of healthcare servicesprovided in late, night and weekendshifts must be reduced.

Many administrative or low-skilltasks, e.g. taking blood samples ordocument management, can beperformed by clerical staff and

medical assistants, freeing doctorsto concentrate on their core tasks:diagnosis and therapy.

However, hospitals will not beprepared to finance increasingpersonnel costs without properassurance that the work time paidis used sensibly. The managementis thus asked to control workfloweffectively and efficiently.

A well-structured workenvironment can help to increaseefficiency. However, a prerequisite,namely standardisation of medicalprocesses, has not yet beenrealised. Organisation still happensby rule of thumb, despite the factthat the introduction of DRGs andthe concomitant financingproblems should have createdsufficient pressure to reconsiderinternal structures.

Technical approaches to identify,measure and calculate major andminor processes in hospitals arevery promising. Frequently only afew major processes need bestandardised to realise significantefficiency gains. The crucial, in

essence cultural, precondition tobring about this change is thewillingness and discipline tofollow these standards.Medical career The traditional career path –specialised medical training thatleads either to a high-statusprivate practice or to a hospital‘tenure track’, i.e. to positions asassistant medical director andeventually medical director –seems a decreasing option foryoung physicians who are wellaware of the financial and thereform pressure burdening thehealthcare system. A newgeneration of physicians istherefore prepared to considercareer alternatives. Consequently,hospitals should offer attractive,adequately paid jobs below themedical director level, whichcome with status, long-termperspectives and allow a decentwork/family balance. One optionis to create a new medical middle-management level for physicians –so-called functional assistant

The Aachen-Maastricht Alliance

The RWTH Aachen University Hospitaland the Maastricht University Hospitalwith their corresponding medical facul-ties are located centrally in the EUregion Meus-Rhine. Because of theirsimilar structures and range of medicalservices their synergetic potentialregarding research, teaching and patientcare is very high.

With their partnership the universityhospitals strive to establish a commonleading position: a European Centre ofReference.

With the cooperation agreement,signed on June 8, 2004 in the LandParliament of Maastricht, the ExecutiveBoards of both hospitals confirmed theirintention to intensify the co-operation.Meanwhile, both medical faculties havejoined in this project. Such a (trans-national) co-operation agreement isunique in the European hospital sectorand in university medicine in Europe.

Cancer care advances – but at what cost?

Objectives and opportunitiesof further intensifying theco-operationSince spring 2007, the Executive Boardsof Maastricht UMC and the UniversityHospital Aachen have carried out anongoing feasibility study that examinesthe objectives and opportunities to cre-ate a leading European UniversityCentre for top medicine.

The combination of the two individualforces will significantly improve the cor-

responding national position. Astronger profile development will befacilitated. In addition, the strategicalignment and excellent positioning ofRWTH Aachen University andMaastricht University will offer the bestpossible outline conditions to become aEuropean and worldwide leading insti-tution in growth sectors such as med-ical technology and life sciences. Due tothe increased attractiveness of hospi-tals and faculties in Aachen andMaastricht it will be possible to engageinternational outstanding and capableinstitutions and scientists. Further bene-fits will result from the achievement ofan internationally competitive criticalmass, complementarities and synergiesin scientific resources, teaching capaci-ties, management competence andmachinery equipment.

MEDI-CLINIC STEPS INTO EUROPELast August, when the South Africanhospital group Medi-Clinic Corporationacquired Hirslanden, Switzerland’sbiggest private hospital group, thecompany not only took its first stepinto Europe, but progressed its strategyfor the geographical expansion of itscore business – acute medicine ‘in con-junction with superior nursing care’.

‘Hirslanden has found a long-timestrategic partner that has the samefocus as us,’ said Dr Robert Bider,Hirslanden’s CEO since 1990. ‘We areconvinced that this partnership holdsgreat potential for the future.’ Thepatients are unaware of a change inownership; the logo has been retained;

the hospitals are characterised by thelocal market and legislation and thesame, as well as enhanced, level of care,with no effects on the staff. There are noplans to sell off any of the hospitals.

Robert Bider said interest in furtherSwiss acquisitions is keen, but Medi-Clinic wants to tackle internationalgrowth systematically. ‘Concepts arecurrently being developed. Structuresand processes must be compatible sothat the synergy can be exploited, andexperience and knowledge exchanged.Access to teaching and research isessential for private institutions, but dif-ficult where the university landscape isdominated by the state. Thanks to

today’s modern means of communica-tion the establishment of an internation-al private university-related organisationappears absolutely realistic. For exam-ple, Medi-Clinic is strongly rooted in auniversity-linked sector. The group isdirectly involved in the training of spe-cialists and in research at five medicalfaculties. Moreover, it is responsible forthe first privately managed universitymedical centre in South Africa.’

Dr Edwin Hertzog, President of theAdministrative Board of Medi-ClinicCorp. Ltd, and Hirslanden CEO Dr RobertBider will report on this development atMCC Hospital World 2008 (www.hospi-talworld.info).


International experts in hospital management and business will speakat the MCC Hospital World 2008 (Berlin, 8-9 September). Here, Dr GuyPeeters, CEO of Academic Ziekenhuis Maastricht, and Dr Robert Bider,CEO of the Hirslanden Private Hospital Group, summarise theirpresentations on the creation of a European University Medical Centre

Dr Guy PeetersDr Robert Bider

EUROPEAN HOSPITAL Vol 17 Issue 3/08 3


Implementation example:Vascular SurgeryThe European Vascular CentreAachen-Maastricht serves as a lead-ing example for the development ofcollaboration in cardiothoracicsurgery, cardiology and interventionalradiology.

The partners established a jointCentre for Vascular Surgery: Eachhospital has fully employed physicianand nursing staff, whereas the direc-tor of the centre, Professor MichaelJacobs, travels between both loca-tions. Communication with staff ispossible by video conferencing.Moreover, corresponding technologi-cal solutions enable Maastricht UMCto retrieve information, e.g. patientfiles stored in Aachen and vice versa.An IT system has been developed toenable neurophysiologists to monitortop-level thoraco-abdominal aortaaneurysma (TAAA) surgery in Aachenfrom their department at MaastrichtUMC. The European Vascular CentreAachen-Maastricht was accreditedrecently.

More details of this project can beheard at the MCC Hospital World2008 (www.hospitalworld.info) meet-ing in September.

Medi-Clinic, the S. Africa-based privatehospital group, was founded in 1983 byDr Edwin Hertzog, its presentAdministrative Board President, withthe support of the Rembrandt Group.The corporation unites 50 hospitals (c.7,000 beds; 13,000 staff) most of whichoperate the affiliated doctor system.

The Swiss Hirslanden private hospitalgroup, established in 1990 by aHirslanden Clinic merger with four clin-ics owned by the American MedicalInternational (AMI) Group. The groupnow owns 13 hospitals (c. 1,300 beds;4,500 employees). Dr Robert Bider hasbeen CEO since 1990. In 2007,Hirslanden changed hands from the pri-vate equity group BC Partners to theSouth African corporation Medi-Clinic.

medical directors who arespecialised and manage theirspecialised field. While thiswould increase personnel costs italso – and more importantly –would increase hospitalperformance. Nursing servicesSince the early 90s, nursing staffis increasingly skilled andtrained. While many nursesacquire additional qualificationsand specialisations, the majorityof their tasks are housekeeping,self organisation and messengerservices, which account for 75%of their work time – yet are tasksfor which most nurses areoverqualified. To improve costefficiency, simple tasks can beallocated to other functions.There are already successfulpilot projects underway in whichnurses’ assistants, housekeeping,service and hotel staff areemployed.

On the other hand, highlyqualified nurses could assumemore responsibility and performboth medical and casemanagement tasks. It remains tobe seen, though, whether nursingstaff are willing to assumemedical assistant tasks andwhether doctors are prepared tohand over case and processmanagement tasks to nurses.Key issue: logisticsHospital traffic is immense:Hospital hallways buzz with staff,permanently on the move. They

accompany patients toexaminations, hand carry reports,files and images because theelectronic patient record (EPR) isstill not a reality. Long distancesbetween diagnostic, treatment,surgery and care facilities,scattered all over a hospitalcomplex, force staff to spend moretime in transit than in theworkplace where they belong.These superfluous logisticalprocesses generate superfluouscosts of around 20%. Today, PACS,digital ordering, EPRs andelectronic scheduling, as well aselectronic stock and purchasemanagement, are all possible andshould be minimum standard. The

core work areas of a hospital mustbe restructured. With short routesand short waiting times, staff willperform better and patients will bemore satisfied.Data management to supportdecisionsHospital management has manypossibilities to optimise theeconomics of medical treatment.Over the last few years, the ‘profitaccounting centre’ at the Institutefor the Hospital RemunerationSystem (Institut für Entgelt-kalkulation im Krankenhaus –InEK) has gained wide acceptanceas a decision-making support tool.It provides benchmark-orientedprofit and loss accounting as well

as continuous DRG calculation,which generates actual cost datafor each case. Excess costs as wellas shortfalls are identified andtheir causes can be analysed.

All required data areautomatically culled from theoverall hospital information systemand from functional sub-systems.For hospitals a professionalsoftware solution is asindispensable as the above-mentioned standardisation ofprocesses. EmpathyA major success factor of anyhospital is the level of empathypatients receive. But today, in theface of organisational and

structural weaknesses, empathyfar too often falls by the wayside –a fact deplored by patients andstaff alike. In modern society the avoidance of suffering plays an enormous role and, in additionto any pain therapy, human-centred emphatic care can workwonders. If we conclude that, inthe current system, empathy hasbecome almost impossible, weneed to ask who can serve as amodel and how can we improvethe situation. The organisationaland structural changes suggestedabove are not merely technocratic,on the contrary, they all aim forone goal: to make empathypossible again.

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EUROPEAN HOSPITAL

News & Management . . 1-8

Radiology . . . . . . . . . . . .

9-12

Lab & Pharma . . . . . . . . 13-15

Surgery . . . . . . . . . . . .

. 16-17

Wound care . . . . . . . . . 18-20

Hygiene . . . . . . . . . . . .

. 21-23

contents

T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K

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1-8 News & Management

● Design: healing

landscapes

● Privatised medicine

in Russia

● Hospital

restructuring and

the law

18-23 Wounds/Hygiene

● Britain’s bug busting

● Russia’s unique wound surgeon

● Hair follicles

help wounds

● Dressings

and new

beddings

16-17Surgery

● The new EU mesh

tech centre

● 20 years of MIS

● Tackling obesity

surgically

Smile please, nurse!

UK – Following a 6-month inquiry in 2007

on how to improve the National Health

Service (NHS) (and patients’ organisations

urging action over an apparent decline in

nursing care since the domination of the

hospital matron was curtailed) one of the

proposals put in a Downing Street Cabinet

meeting was that doctors and nurses

should smile more.

Now a pioneering pilot training scheme

is underway in Stockport Hospital, Greater

Manchester, which aims to put smiles on

nurses’ faces when working with patients –

and more. Under a new edict, nurses are to

be banned from discussing personal mat-

ters, except during breaks, or to speak loud-

ly during night shifts. Another point: Never

promise a patient ‘I’ll be back in a minute’

if you cannot return do that.

The Patients’ Association (PA) reported

that patients felt nurses had lost the ‘caring

touch’. Many, for example, claimed to be

‘too busy’ to properly feed the elderly,

resulting in malnutrition, whilst others

refused to take on cleaning tasks.

However, the reaction of the Royal

College of Nursing was that it is insulting

to suggest that nurses do not smile

enough.

Also on the side of nurses, Michael

Summers, Vice-Chair of the PA’s Board of

Trustees, pointed out that they now work

under considerable pressure, so can lose

touch with some patients’ needs. ‘Nurses

also qualify in primarily academic degree

courses,’ he pointed out, ‘so when they

start nursing many lack day-to-day nursing

skills.’

LEGIONELLAInsurer initiates preventive

hospitals inspection

UNIQA, Austria’s leading health insur-

er* recently initiated a preventive

inspection of the technical water lines

and systems at around 40 of the hospi-

tals it insures, to identify any possible

contamination by Legionella bacterium.

Following the inspections many of the

hospitals opted to undergo TÜV certifi-

cation. Their motivation is not only med-

ical concern, but also economic and

legal issues.

According to the World Health

Organisation about 10,000 people die

from Legionnaire’s disease annually.

Because an institution, rather than

water supplier, is held responsible for

the quality of its drinking water, an out-

break is not only a health risk, but has

legal repercussions.

‘The authorities are currently

extremely active in this area. Upon sus-

picion of an illness caused by Legionella

contamination, facilities are closed and

can only be opened again when it can

be verified that a risk no longer exists,’

Dr Johannes Hajek, CEO of UNIQA

Sachversicherung, pointed out. ‘For this

reason we decided to assist all hospitals

insured through us in the fight against

Legionella by covering the inspection

and expert consultation costs.’

Following these, the hospitals can

receive a Legionellae-Free Facility TÜV

certificate.

The inspections and sharing of the

expertise were handled by HWC

(Hygienic Water Consulting), a long-

term partner of UNIQA in this area.

In the event of contamination, neces-

sary measures are discussed and imple-

mented. In almost all cases, it is possible

to get the system under control through

adaptation of the usage patterns,

UNIQA reports.

* In May, Uniqa Versicherungen AG

announced its intention to acquire the entire

shareholding of Unita Vienna Insurance Group

(transaction due for completion this autumn).

With 70 companies under its umbrella in

Austria and 15 in CEE countries (Germany,

Poland, Switzerland, Italy, Lichtenstein,

Hungary, Serbia, Bosnia and Herzegovina,

Croatia, Czech Republic, Slovakian Republic,

Slovenia, Ukraine and Romania), in 2005

employees numbered 10,000.

Switzerland’s hospital system is

highly complicated because the 26

cantons each have different regula-

tions. Nonetheless, they all have

one common feature, i.e. billing is

calculated on a per diem basis,

which means that medical insurers

simply pay an agreed amount per

day spent in hospital – independent

of a patient’s diagnosis. Any further

costs are covered by the hospital,

meaning the state or private hospi-

tal operators pay.

Dr Carlo Conti, President of

SwissDRG AG, based in Basle, will

organise the switch to DRGs.

‘There can be no doubt that

the current billing systems in

Switzerland contain some misguid-

ed incentives and are therefore

causing a conflict when it comes to

achieving more efficiency for hos-

pitals. The partners in the health-

care sector and the world of poli-

tics agree that a system change to

DRGs would result in real improve-

ments. National, standardised tar-

iffs would also make it easier to

Switzerland to adopt

DRGs systemachieve comparability and to pro-

mote the exchange of healthcare

services between different geo-

graphical areas within Switzerland,’

he told European Hospital.

What do they hope to achieve?

‘The introduction of DRG case-

based lump sums is to achieve two

things: More transparency of all

medical services offered and pro-

vided in a hospital and ideally a per-

formance-based kind of remunera-

tion. In our Federal structure, the

DRGs will provide a prerequisite

for more competition between the

service providers because services

and products delivered by hospitals

can be compared, regarding cost as

well as quality.’

Switzerland is to adopt the

German case-based system, for

example, although this has now fall-

continued on page 2

The Swiss hospital

system is facing a

radical change. Billing

by Diagnosis Related

Groups (DRGs) is about

to be introduced.

European Hospital’s

correspondent in

Switzerland, Dr André

Weissen,* approached

Dr Carlo Conti (above),

President of SwissDRG

AG to discuss some of

the controversial issues

involved in the

switch to DRGs

Cancer care advances

– but at what cost?

Half a million dollars for one extra month of life

Although incremental improve-

ments in cancer care were unveiled

at the 44th Annual Meeting of the

American Society of Clinical

Oncology held in Chicago, USA, –

the world’s largest gathering of can-

cer specialists, our correspondent

Ian Mason writes that, even as

new study results were being

reported, their cost implications for

stretched healthcare budgets were

questioned.

Professor Robert Pirker, Med-

ical University of Vienna, Austria,

announced results from the FLEX

study (Abstract #3) showing that

combining the targeted therapy

cetuximab with platinum-based

chemotherapy improved overall

survival compared to chemothera-

py alone, when used as a first-line

treatment for patients with

advanced non-small cell lung can-

cer – which accounts for more than

80% of all lung cancers.

The addition of cetuximab boost-

ed overall survival from 10.1

months to 11.3 months, a result that

Professor Pirker described as ‘set-

ting a new standard’ for the first-

line treatment of this dreadful

malignancy.

However, Professor Thomas J

Lynch, Harvard School of Medicine,

pointed out that this modest sur-

vival benefit – just 1.2 months –

came at a cost per life year gained

of $540,000 to $622,080.

The eye-watering cost of such

interventions underscored the

importance of pharmacogenomics –

another major theme at this year’s

ASCO. ‘This exciting field gives

us new tools to identify the most

appropriate treatment for each

patient,’ said Dr Julie Gralow,

associate professor of medicine at

the University of Washington.

In one such study, Professor Eric

Van Cutsem, University Hospital,

Leuven, Belgium reported results

continued on page 2

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Signature Date



Restructuring in the hospital sectorMERGER CONTROL AND OTHER PITFALLS UNDER COMPETITION LAW

The hospital sector has recentlyfaced increased competition lawscrutiny, particularly in Germany.In recent years the German FederalCartel Office (FCO) has made itclear, on numerous occasions, thatmergers between hospitals(private and public) are as muchsubject to competition lawprovisions as any other mergercases. Here, Marc Besen analyses afew recent German merger casesto provide an overview of theimpact of competition lawprovisions on hospitals – and onhospital mergers in particular

The restructuring process in thehospital sector has accelerated overthe last couple of years. For exam-ple, since 2005 the FCO, hasreviewed over 50 hospital mergernotifications.

The first prohibition of a publichospital merger was issued on 13December 2006. The FCO prohibitedthe University Hospital ofGreifswald from taking over theWolgast district hospital. It arguedthat the merger would furtherstrengthen the dominant position ofthe Greifswald University Hospitalin the relevant market. In its deci-sion, the FCO followed the princi-ples established in the earlier merg-er case Rhön Klinikum AG/BadNeustadt (10/3/05). However,despite the basic similarity, the finaloutcome of the two cases was dif-ferent. Whereas in its ruling of16/1/08 on Rhön Klinikum AG/BadNeustadt, the German FederalSupreme Court upheld1 the mergerprohibition, the merger could beconsummated after receiving anexceptional authorisation from theFederal Minister of Economics andTechnology on 17 April 2008.

only the hospital but also any othercommercial activities of the state.Substantive assessment criteria

If a merger is likely to create orstrengthen a dominant market posi-tion, it will be prohibited by the FCOunder sec. 36 (1) of the ARC, unlessthe parties are able to demonstratethat the merger will have a signifi-cant positive effect on competition.A company is regarded as having adominant market position if it is ableto supply or demand certain goods

or services on a specific marketwithout having any competitors orbeing exposed to any substantialcompetition, or if it has a para-mount market position in relation toits competitors (sec. 19 of the ARC).This is presumed to be the case ifthe company has a market share ofat least one third. It is also possiblefor several companies jointly tohold a dominant market position, ifup to three companies have a joint

down in the EU Merger ControlRegulation. The turnover thresholdsfor German merger control weremet both by Rhön Klinikum AG/BadNeustadt and Greifswald/Wolgast.In the latter case the state ofMecklenburg-Western Pomeraniaargued that its total turnover on thehospital sector does not meet thethreshold of €500 million. However,the FCO rejected this assessmentarguing that the relevant turnoverachieved by the state includes not continued on page 6

As a lawyer and partnerat Clifford Chance,Dusseldorf-based MarcBesen primarilyspecialises in Germanand European antitrustlaw. He advisescompanies during theimplementation ofmerger controlproceedings at theGerman FCO and EC

and co-ordinates worldwide multi-jurisdictional filings. He also has broadexpertise in advising interested thirdparties in successfully intervening proposedtransactions within merger control andcourt proceedings. In addition, he focuseson cartel investigations, issues ofcompliance systems, contractualimplementation of competition andantitrust law requirements, and distributionlaw across a wide range of industry sectors(in particular healthcare and hospitals).

Relevant provisions

Turnover thresholds

In its ruling on Rhön KlinikumAG/Bad Neustadt the FederalSupreme Court supported the viewof the FCO and stated that hospitalmergers are subject to merger con-trol provisions in accordance withthe provisions of the German Actagainst Restraints of Competition(ARC). As the ARC does not distin-guish between mergers of privateand public undertakings, the merg-er control provisions apply irre-spective of the legal status of thehospitals concerned.

Mergers (incl. the acquisition ofat least 25% of shares in a company,etc.) must be notified with the FCOif the total global turnover of theparties involved exceeds €500 mil-lion and if at least one of the com-panies involved generates turnoverin Germany exceeding €25 million.The fact that such mergers do notnormally take place in so-called de

minimis markets (which areexempt from German merger con-trol provisions) means that mergerapplications may only be dispensedif a company having generated glob-al turnover of less than €10 millionin the last fiscal year (including par-ent company and subsidiaryturnover) merges with anothercompany. Mergers must be notifiedwith the European Commission ifthe total global turnover of the par-ties exceeds the threshold laid

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Moreover, the FCO may imposesevere fines on the parties, whichcan amount to up to 10% of theoverall turnover generated in theprevious financial year.

There are also other potentialforms of cooperation between hos-pitals in addition to mergers thatneed careful consideration underan antitrust perspective beforebeing put into practice. The maintypes of cooperation affected areagreements on specialisation orregional focus and joint purchasingarrangements in particular. The lat-ter can become critical when thejoint market share held by the par-ties involved is 15% or more.Certain risks are also associatedwith long-term supply agreementsincluding exclusive supply arrange-ments, non-competition clauses orother exclusivity provisions. In gen-eral, there are also considerableantitrust risks related to taking partin meetings held by professionalassociations or in committees ortrade fairs where these involvemeeting with competitors. The pro-visions of the ARC prohibiting theabuse of a dominant market posi-tion are also relevant (e.g. discrimi-nation, predatory pricing, etc.).These anti-abuse provisions mayalso apply to smaller hospitals witha strong market position in theircatchment areas. 1At the time of the draft of this article,

the full statement of grounds was not

yet published by the Federal Supreme

Court.

market share of at least 50% or fiveor fewer companies have a jointmarket share of at least two thirds.These thresholds are likely to bemet on a regular basis in the case ofhospital mergers given the overlapsin catchment areas resulting fromthe regional market set-up.Market definition

The central issue in both mergercases was the determination of therelevant market and thereby of therelevant market shares.

In both cases the relevant productmarket was defined as the marketfor acute hospital services compris-ing all general hospitals and spe-cialised clinics, but not rehabilita-tion and other nurse centres.

The geographical scope of themarkets was defined regionally bythe FCO. The main criteria for theregional delineation was thepatient flow, which itself dependedon the hospitals in the vicinity ofthe patients offering a genuine pos-sibility for treatment. In both merg-er cases the market definition wasbased on a comprehensive analysisof the market conditions.

This means that, for the purposeof hospital mergers, the market isdefined quite narrowly both, interms of the services offered andthe relevant geographical territory.As a consequence, some hospitalswill be considered to have a domi-nant market position in their catch-ment areas even if they have a rela-tively low turnover.

federal states, it must also be takeninto consideration that the relevantturnover of the acquirer includesthe whole turnover achievedthrough all its commercial activi-ties. This means that hospital merg-ers involving a public acquirer arevery likely to exceed the thresholdsset out in the ARC.

A second, separate issue are theconditions that must be met toobtain FCO clearance. The initialconsideration would be whetherthere is any regional overlapbetween the catchment areas of thehospitals concerned. The next keyfactor is whether the merger wouldcreate or strengthen a dominantmarket position on the relevantmarket.

From Greifswald/Wolgast it canbe concluded that mergers betweenpublic undertakings in economical-ly underdeveloped German regionsprobably have better chances to begranted ministerial authorisationunder sec. 42 of the ARC. Itremains to be seen whether theFCO will adopt a similar legalposition.

RisksIf a merger triggering German merg-er control is not notified beforeclosing at all, or not correctly noti-fied, this may have a number of con-sequences under civil and regulato-ry provisions. The first conse-quence is that the underlying pur-chase agreement is void accordingto sec. 41 (1) 2 of the ARC.

Planning pathways to a peaceful endAnnick Chapoy reports on the landscaping of the Centre Hospitalier Emile-Roux in France

People here have reached the end of theirlives. After a tour of the vast grounds of theCentre Hospitalier Emile-Roux, just 20 min-utes south of Paris, we come upon a famil-iar scene: two wheel-chairs with three peo-ple in attendance, one a nurse. For land-scape architect Olivier Damée, co-founder of DVA Paysages in Paris, what ismore unusual – and so meaningful – isthat, each carries a bouquet of lilac, pickedto decorate hospital rooms. Olivier plantedthat lilac and today’s gathering signifiesthe success of his dream.

When, four years ago, he took up hiscommission to remodel the entire groundshere – all 25 acres – he faced a hospitalwith history. Apart from a lane leading toBrévannes castle (built 1786) and thegreen and planted areas in its vicinity, thegeneral visual impression was chaotic.Across this vast area are a great number ofbuildings, in all styles and sizes (some builtin C.17th), as well as much scatteredequipment. The more recent buildingsappeared – without coherence – duringthe 20th century. Between these, all thespace was reserved solely for vehicles.Departments had to be reached by crossingthem, Olivier Damée recalled. This was notjust hard on pedestrians but a nightmarefor the hospital’s multi-handicapped andelderly patients. His diagnosis: anarchicpractices, interrupted pedestrian flow andwalking generally impractical.

For the design project he decided toadapt the Hospital Emile Roux to contem-porary needs as well as emphasise theBrévannes castle history – a rare testimonyto neoclassic architecture in this Val deMarne area.

The hospital’s clinical requirements pre-sented specific constraints: each handicaphas its own characteristics and specialneeds. Whereas some patients can use awheel chair or just a helper, others areblind and some multi-handicapped. Inremodelling, it was essential to meet alltheir needs – access, rest along the way,clear directions despite the uniformity ofpath widths, elimination of obstacles.Paths – The environmental perception ofsomeone in a wheel chair, whose eye isabout 1.20 metres above the ground, wascarefully studied. Additionally, the level offatigue in the elderly was consideredbefore creating circuits for them to walk indifferent lengths of time, with ‘kiosks’ inwhich to rest along the way.

Today, the paths are indeed continuous,firm, neither slippery nor shiny and they areuncluttered. Their colour is also differentfrom the roads for vehicles, and the texturechanges at each crossroad for better iden-tification by the walking sticks of the blind– and they are bordered with a materialpleasant to the feet or stick. At two metreswide, they can accommodate two wheel-chairs side by side.

The development of private medicine in Russia has reached anew level, according to Sergej Anoufriev, CEO of the StPetersburg Association of Clinics (set up by 13 private clinics twoyears ago). Private clinics have become a real part of the Russianhealthcare system and people increasingly choose private med-ical services. However, the state and private organisations solvethe same problems differently. Thus we must seek and find com-mon ground for the sake of our patients. The Forum was theimportant step on this road because the state officials, publicagents and the private clinics leaders worked together over thethree-day event.

Today, in Russia, no one doubts that healthcare will be morequalitative and more effective when private clinics and centresgain state support, and partnership will become the main princi-ple of the relationship between state and private medicine.

Russia has twice the number of hospitals than the EuropeanUnion. However, about 50% of these cannot provide patientswith modern, quality treatment. At the same time, the illegalmedical market turns over about US$15 billion annually – i.e.money paid by patients straight into doctors’ pockets.

50% of Russians never go to a state hospital – and those arethe most actively employed. They pay taxes for state healthcare,yet often seek private treatment.

St Petersburg has about five thousand out- and in-patient hos-pitals; only about 10% of medical services are provided by pri-vate centres. Experts, however, talk about the arrival of severalnew, big private clinics in the near future.

Generally, private clinics are set up by the most active physi-cians, Sergej Anoufriev pointed out. They need about US$50,000 to100,000 to fund a private centre. Today, however, the ‘ticket’ to amedical business is worth between US$500,000 to 900,000. It’sserious business, which needs necessary and serious investments.

The Forum’s participants signed a document stating that health-care system reform will be more successful and more effective ifprivate clinics are included in state healthcare programmes.

Private medicineA Russian evolution

In the Bad Neustadt market, inwhich Rhön Klinikum AG alreadyowns five clinics, Rhön would have– according to the findings of theFCO – increased its market sharefrom 25% to approx. 65%. In theGreifswald market, the FCO con-cluded that the market share of theGreifswald University Hospitalwould have increased by 25% toapprox. 80% of the overall marketand, concerning some specialiseddepartments, such as surgery orgynaecology, to approx. more than90%. In both cases, the FCO foundthat a market dominating positionwould have been created/strength-ened and, since the parties had notbeen able to demonstrate significantpositive effects on competition, themergers were prohibited.Ministerial authorisation

Under sec. 42 of the ARC, theFederal Minister of Economics andTechnology shall, upon application,authorise a concentration prohibit-ed by the FCO, if the restraint ofcompetition is outweighed byadvantages to the economy as awhole following from the concentra-tion, or if the concentration is justi-fied by an overriding public interest.Prior to the decision the FederalMinister of Economics andTechnology shall obtain an opinionfrom the Monopolies Commission.The Monopolies Commission consti-tutes an independent advisory boardto the Federal Government concern-ing merger control and other topicalissues of competition policy.

Despite the basic similaritiybetween the two merger cases, theministerial authorisation wasrejected in the case Rhön KlinikumAG/Bad Neustadt, but theGreifswald/Wolgast merger wasapproved by the Federal Minister ofEconomics and Technology, whobasically followed the argumenta-tion of the Monopolies Com-mission. In Greifswald/Wolgast theMinister argued that the merger canbe justified by the overriding publicinterests in the long term preserva-tion of the medical faculty and theaffiliated hospital of GreifswaldUniversity. The second overridinginterest approved was the furtherdevelopment of the exploratoryfocus of ‘Community Medicine’being a unique selling point of theUniversity of Greifswald. Bothaspects are expected to establish anexclusive research region of ‘ModelRegion Eastern Pomerania’.What conclusions can be drawn

from the two merger cases?

First, hospital service providers aswell as investors must comply withthe merger control law provisionsjust like any other undertaking. Thisprinciple applies irrespective of thelegal nature of the hospitals, i.e. forboth private and public hospitals.However, not every hospital mergerin Germany requires a notification,where the only mergers that triggera merger filing are still thoseexceeding the ARC turnover thresh-olds. Having said that, in casesinvolving public entities, such as

The décor of the park, kiosks, fountainsor ponds helps patients to navigate, with-out being an obstacle. The kiosks, providingshelter, toilets, benches, and nurse alarms,are placed every 60 or 100 metres.Benches – Created to retain neither heatnor cold, the benches have back and arm-rests and the seats incline to resist rain. Ametre separates each bench, providingspace for a wheelchair.

Not higher than 90 cm, the waste binscan be manipulated with one hand. Theyalso are on the ground to enable the blindto tap and locate them.Lights – Any sudden change in luminancecan lead to orientation problems, especial-ly for the partially-sighted. For patient safe-ty and to avoid any loss of landmarks,lighting equipment must be coherent andcontinuous. Lights illuminate the paths inareas used at night, as well as at pedestri-an crossings over roads. The angles of lumi-nous rays are controlled to eliminate glareand reflection.

Light from lamp post intersect at aheight of 2.10 metres minimum. Glarefrom lower sources of light (under 1.5metres above ground) does not occur.Planting – The designer divided the exist-ing large lawn in to four distinct and com-plementary zones: a forest; valley of flow-ers; large prairie from which to admire thecastle, and a huge orchard.

Various areas focus on the sensory envi-ronment – of touch, scents and sounds –particularly valuable for the blind.Woodland of modest height and low den-sity absorb noises, whereas a thick, highhedge acts like a wall. The sound of a foun-tain is important as a guide for the blind orpartially-sighted, for they have less audito-ry landmarks in a park compared with astreet.

Triple rows of linden trees now line themajestic route to the monument, and theorchard planted next to the castle is anideal attraction for ambulatory patients. Inall, there are three kilometres of traffic-freewalkways.


Sergej Anoufriev, CEO of theSt. Petersburg Association of Clinics

Olga Ostrovskaya reports on the firstSt Petersburg medical forum Private medicine in Russia:Problems and ways of evolution, which took place in

June. Organised by various medicalassociations, the main goal was toexchange experiences in private medicineand shape proposals to create a productivestate policy in this sphere



UK – The NHS is still suffering fromwide variations in infection controlstandards, according to a survey ofhealth staff in the UK.

The study carried out by thewatchdog body the HealthcareCommission, after questioning morethan 155,000 NHS staff, indicatedthat there had been improvements ininfection control in several areas.

This was reflected in 82% of staffsaying their trust did enough topromote the importance of hand-washing to staff, up from 70% in2005.

There was also an improvement inthe number of staff trained in infec-tion control, up from 68% in 2005 to71% in 2007.

However, the Healthcare Com-mission said work still needed to bedone in hospitals in parts of the UKto ensure that hand-washingequipment was always available tostaff when they needed it. In 2005,60% of staff said hand-washingequipment was available but in thelatest survey, this had only risen to61% with wide variations betweenhospital trusts.

Healthcare Commission chiefexecutive Anna Walker said: ‘At atime when public concern abouthealthcare associated infections isso high, I’m pleased to see someimprovements in this area. Buttrusts must make sure that frontlinestaff always has the necessaryequipment to wash their hands.There are trusts that have shownthat it is possible to do this well,with as many as 82% of staff sayingthey always had equipmentavailable. But this fell to as few as39% at other trusts. Every trustshould be aiming to make this 100%.’

In Britain, Prime Minister GordonBrown ordered a ‘deep clean’ ofevery hospital ward last year as apre-emptive move to halt the spreadof nosocomial infections such asMRSA.

Various practices have beenintroduced in UK hospitals to thisend – one, in Plymouth, for example,which had the highest number ofMRSA deaths in England with 94between 2002 and 2006, now has allserious cases of MRSA andclostridium difficile infectionsreviewed by senior managers.

Another NHS Trust reports it haseliminated MRSA bloodstreaminfections by stopping the routinepractice of administeringintravenous injections. (See page 23

for a roundup of UK approaches to

control nosocomial infections.)

However, although the NHS hadexperienced a continuous drop inMRSA outbreaks since April 2006,the most recent figures show a slightrise in cases. The Health ProtectionAgency said cases between Octoberand December 2007 stood at 1,087,up 0.6%, meaning that Britishgovernment targets on reducingcases may not be met.

The Healthcare Commission willcontinue to monitor performance ofhospital trusts against the HygieneCode in the UK.

Other findings from theHealthcare Commission survey ofNHS staff, which covered 391 NHStrusts, found that staff weregenerally satisfied in their jobs, that94% took part in some form oftraining but that more action is

needed to address violence andabuse, which research suggests isrelatively high in the health sectorcompared to other workingenvironments.

Ms Walker said: ‘The results showthere are a lot of reasons to work inthe NHS. But there are challenges to

NHS survey finds wide variations in control standardsNosocomial infections

Report: Mark Nicholls

Healthcare CommissionCEO Anna Walker

making the NHS a better place towork.’

* In Scotland, a year-long pilotscreening programme for MRSA inhospitals was announced by thecountry’s Health Secretary NicolaSturgeon. Almost one million peoplewill be given nasal swabs to test forthe presence of MRSA. If detected,they will receive treatment to clearthe infection.

GE Healthcare

GE imagination at work

© 2008 General Electric Company GE Medical Systems, a General Electric company, doing business as GE Healthcare.

The sooner the better. Never did that phrase ring more true thanwhen treating illness. From predicting and diagnosing to monitoring,treating and informing, GE Healthcare dedicates its resources to helphealthcare providers stay as many steps ahead of illness as possible.Because the earlier the detection, the sooner we just might bringdisease to an end. Healthcare Re-imagined.

To learn more visit www.gehealthcare.com

The end of diseasestarts at the beginning.

E D U C AT I O N & N E T W O R K I N G



What singles ResearchGATE outcompared to, for example, usingFacebook for social networking?Dr. Madisch: It’s a social network tooladapted to a researcher’s needs, i.e.optimized to present yourself in the context of your research.ResearchGATE enables you to get intouch with colleagues internationally;to stay informed about their actual pro-jects and latest publications, as well astheir contact information and the liter-ature they read. We want to combinevarious Science 2.0 applications inorder to create a unique collaborativeenvironment.

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NUTRITION AND HEALTHMalnutrition in the elderlyWhile many adolescents and adults are struggling with overweight, malnu-trition is a serious problem for many older people, particularly those abovethe age of 70. European research results indicate that 15-40% of the elderlyadmitted as in-patients suffer from malnutrition.

Frequently, a poor nutritional state is caused by chronic diseases, demen-tia, disorders in the mechanisms that regulate hunger and satiation, loss ofsense of taste and problems with chewing. An estimated 50-70% of peoplein long-time care suffer from malnutrition, while for old people living in theirown homes, the figure is 15%.

A first indicator for malnutrition is the body mass index (BMI). Patients withlow weight resp. a low BMI (< 18.5) can be assumed to be in an overall poornutritional state. When patients are losing weight rapidly, their weight shouldbe measured over time to be able to assess and minimize the risk.

Malnourished people have low protein levels, which in turns compromisestheir immune system, muscle mass disappears, wounds tend to heal less welland, due to lack of calcium, bone fractures happen more often. Particularly inolder peoples these conditions mean loss of independence and quality of life,since decreasing muscle mass makes walking and standing upright difficult.

Identification of the nutritional state via BMI requires scales and othermeasurement tools of utmost precision. Scales with handrails that facilitateclimbing and standing on the platform help both healthcare workers andpatients. seca gmbh & co. kg, Hamburg, Germany, offers a broad range ofproducts that are ideally suited for older patients such as scales with largeplatforms that provide ample space for a second person, or a chair so the per-son can be weighed while sitting. The additional weight is tared and the netbody weight is displayed. Source: Seca

Nurses spend 1.6 millionhours weekly on form fillingUK – A plea to hire more ‘ward clerks’ to free hospital nurses fromexcessive bureaucracy has been made by the Royal College of Nursing tothe government and change NHS targets so as to place more emphasis onpatient satisfaction and hygiene standards.

The excessive hours nurses spend on tasks that keep them away frompatient care were highlighted at the RCN annual conference this April,based on an ICM poll of over 1,700 staff nurses. This revealed that theyspend, on average, 7.3 hours weekly filling in forms; part-time nursesspend some 3.9 hours in this way. Figures for nurses in managerialpositions, obviously expected to spend more time on administration, werenot included. The total hours of bureaucracy amounted to over a millionweekly.

Peter Carter, the RCN general secretary, pointed out that 88% of the pollrespondents had experienced an increase, in the last five years, in theamount of bureaucratic tasks that did not need their professionaljudgment. These include filing, photocopying and ordering supplies. Over28% pointed out that they had no access to clerical help. Only 22%believed administrative back-up has kept pace with the growth inbureaucratic demands.

Government ministers are being asked by the RCN to introduce newkey care quality indicators, including patient satisfaction, complaints,cleanliness, infection rates, food, drug errors, communication and dignity.

During the 2nd European

Workshop on Diabetes, hostedby Bayer HealthCare DiabetesCare, experts called foruncompromising management ofdiabetes.

Professor Oliver Schnell, ofthe Diabetes Research Institute,Munich, stressed the value of

blood glucose testing. Numerous studies have shown that regular self-testing makes a significant contribution to improving outcomes andmanagement of complications.

The special significance of post-prandial blood glucose values in thiswas emphasized by Professor Antonio Ceriello, of the ClinicalSciences Research Institute, Warwick Medical School, UK. Unlike thoseof healthy people, the blood glucose levels of people with diabetes fallonly slowly and often insufficiently after glucose uptake – aphenomenon that the International Diabetes Federation has taken intoaccount in its Guidelines for the management of post-meal glucose.Professor Ceriello, Chair of the IDF Steering Committee, summarizedits recommendations as follows: ● Post-meal hyperglycemia is harmful and should be addressed. ● A variety of both non-pharmacological and pharmacological therapies

should be considered to target post-meal plasma glucose. ● Two-hour post-meal plasma glucose should not exceed 7.8 mmol/l

(140 mg/dl), as long as hypoglycemia is avoided. ● Self-monitoring of blood glucose (SMBG) should be considered

because it is currently the most practical method for monitoring post-meal glycaemia.

● Efficacy of treatment regimens should be monitored as frequently asneeded to guide therapy towards achieving post-meal plasma glucosetarget.

MOVING TOWARDS SCIENCE 2.0Ijad Madisch studiedmedicine and computerscience, and was aresearcher at HarvardMedical School, Boston,for two years. Hisdoctorate was gainedfor a thesis onmolecular virology

Despite the importance of networking and interaction between researchers and scientistsno social networking platform dedicated to researchers existed before ResearchGATE(www.researchgate.net) went online. Designed to facilitate efficient peer-to-peer contact,this network allows researchers to post their profiles, a CV, publication list and researchskills. On behalf of European Hospital, Dr Sönke Bartling, a researcher at the German CancerResearch Centre, Heidelberg, and advocate of Science 2.0, interviewed Dr Ijad Madisch,co-founder of ResearchGATE, about the concept and benefits of this social network

Doctors across Europe now have freeaccess to the British Medical Journal’slibrary of Continuing Medical Education(CME) and Continuing ProfessionalDevelopment (CPD) content.

With ‘revalidation’ of medical trainingbecoming a real threat in many EUcountries, the availability of unbiased,peer reviewed, accredited CME willbecome increasingly important,explained Dr Michael Chamberlain,Chairman of the BMJ Group, adding:‘Medical knowledge is changing at sucha rapid rate, that a physician’s knowl-edge needs replacing every sevenyears.’

Pharma company Eli Lilly has increasedan existing partnership with the WorldMedical Association (WMA) by gran-ting c. 646,505 euros to expand onlinetraining courses for physicians onmulti-drug resistant tuberculosis(MDR-TB), which they have beendeveloped over the past year. Thecourse aims to help physicians to moreeffectively diagnose, prevent and treatMDR-TB. Clinical guidelines weredeveloped and harmonised with evi-dence-based material sourced from theWHO, International Council of Nursesand the International HospitalFederation.

The course was tested among physi-cians in South Africa.

The German Medical Associationgave managerial support for the con-ception of the project, and theNorwegian Medical Association adapt-ed the material to a web-based formatand will provide CME credits to courseparticipants.

The new four-year joint partnershipagreement was signed in Geneva inMay by Jacques Tapiero, president

ic way of collaboration. Through oursearch engine you can find a researcherspecialized in specific fields, so it’s easyto find someone who may be a big help.Just search for their research skills.Given the importance of collaborationfor researchers we developed a newapplication: REstoRY (Research StorageHistory) – a smart file and data sharingapplication. Several other features arealready available. However, driven byideas and feedback of the scientificcommunity we are continuously devel-oping new applications tailored toresearcher’s needs.What is Science 2.0?We have all heard about this evolution -some people call it revolution – withinthe internet widely known as Web 2.0.Let us take encyclopaedias. For decades

they were hardcovers on the bookshelf,then followed a static online version.Finally encyclopaedias were revolution-ized by Wikipedia. Within science – andespecially publication within science –we are currently in the static onlinestage. Science and scientific publica-tion almost completely lacks modernconcepts that Web 2.0 offers, whichwill change through Science 2.0. This isalready happening, old fashioned labnotebooks have given way to Wikis,and the amount of open access jour-nals is increasing. Nobody knows howscience in the future will look – butwith ResearchGATE we want to sup-port that change. ResearchGATE is apart of the Science 2.0 community andwill evolve with the community fromscientists for scientists.

ResearchGATE: the first socialnetwork for researchers

WMA gains funding tosupport TB training course

of Lilly’s intercontinental operationsand WMA president Dr Jon Snaedal.‘Given adequate healthcare infrastruc-ture and adherence to proper medica-tion regimens, MDR-TB is not onlytreatable, but indeed curable,’ saidJacques Tapiero. ‘This online trainingcourse is an important addition to thealready existing tools and activities ofa larger partnership of 16 public andprivate organisations worldwide dedi-cated to fighting MDR-TB.’

Dr Snaedal added that the coursewill now be made more interactive,with more case studies and a progres-sive learning pattern. ‘A TB refreshercourse is important to get physiciansback on track regarding the basicknowledge of standard TB,’ heexplained.

Currently in English, the onlinecourse is being translated into Spanish,French, Chinese and Russian. It willalso be published in handbook and CDform.FREE course access: www.WMA.net/ Or via the Norwegian MedicalAssociation: http://lupin-nma.net/

BMJ gives EU doctors free access to CME

Cardiology atthe Crossroads

This May the Brussels-basedCrossroads Institute for Cardiac andVascular Medical Education launchedtwo new educational courses on theprevention of amputation (peripheralvascular disease) and on improving thetreatment of women with cardiovascu-lar disease.

These complement the Institute’sextensive portfolio of ‘hands-on’ train-ing for interventional cardiologists,nurses and pharmacists. Over 50 of theInstitute’s courses are CME-accredited.‘To date, more than 14,000 physicianshave participated,’ said Prof. JeanMarco MD, course director for theCrossroads Institute.

Virtual simulators and a virtual in-house catheterisation lab enablephysicians to practice the latest incardiac and vascular therapies. Livecase broadcasts from hospitals acrossEurope demonstrate real-time cathete-risation lab events.

Programmes offered include the lat-est stenting techniques (e.g. bio-absorbable stents); revascularisationstrategy in diabetics; stenting high riskpatients; prevention and managementof PCI complications.

The Institute and its education pro-grammes are sponsored by AbbottVascular, but course content is decidedby an independent steering committee.

Languages: Mostly English, but otherEU language-courses are available.Details: www.crossroads-institute.com

More than half a million physiciansalready use univadis, but only nowhave access to BMJ Learning. Underthe new scheme, started in June, EUprimary care and hospital physicianscan access 350 interactive learningcourses from BMJ learning atwww.univadis.com (sponsored byMerck Sharp and Dohme). Until now,the most popular CME modules havebeen Childhood Fever, and Avian Flu.

Languages: The courses are beingtranslated first into Spanish, German,French and Italian, to be followed byother EU languages.Report: Ian Mason

DIABETES MANAGEMENTProfessor Antonio Ceriello (left)and Professor Oliver Schnell

R A D I O L O G Y


Today, Iceland counts 53 personalhealth clinics, widely scatteredacross the nation, which, despiteits relatively small population,encompass a land area nearly thesize of the UK. A combination ofhospital-based PACS technologyand remote computed radiography(CR) units from Agfa HealthCarewill now help many Icelandersreceive prompt medical careregardless of location.

LUH had originally installed abasic PACS from Agfa HealthCarein 1997 linking various digitalmodalities within its radiologydepartment, as well as worksta-tions in other hospital-based loca-tions. A comprehensive CR systemwas added in 2003. More recently,it upgraded to a newer IMPAXPACS version with an expandednetwork that included nearby clini-cal locations outside the main hos-pital campus.

Thorgeir Palsson, ClinicalEngineering Manager at LUH,explained: ‘Growing our PACS overthe years clearly demonstratedhow we could link and archiveimages from various modalities, aswell as make data available toother in-hospital sites. We also sawthe speed, workflow improve-ments, performance reliability andimage quality benefits of distribut-ing digital imaging and information.Going digital meant no more filmprocessing, with all the causticchemicals and strong odors,’ headded. ‘I also like not having tostore and manage chemical sup-plies, as well as avoiding the hugecost of safely discarding old chem-istry. The CR system is very user-friendly, and I’m pleased with allthe advantages it offers.’

‘LUH physicians and administra-tion agreed it was logical to expandthe network using Agfa HealthCareCR systems, since their experiencewith the original and currentIMPAX products was so positive,and deploying the company’s CRtechnology would be an easy, trans-parent connection,’ Agfa pointedout. ‘As a result, Agfa HealthCarealso deployed CR 35-X and CR 30-XCR systems.’

Performing over 6,000 proce-dures annually, the Keflavik facili-ty’s single CR unit and 11 specialcassettes are in constant use.

The Medical Design Excellence Awardscompetition is organised and presentedby Canon Communications LLC (LosAngeles) and is the only awards pro-gramme that exclusively recognizes con-tributions and advances in the design ofmedical products.

Sectra MicroDose Mammographyhas been given the 2008 Medical DesignExcellence Award. Entries are evaluatedon the basis of their design and engi-neering features, including innovativeuse of materials, user-related functionsthat improve healthcare delivery andchange traditional medical attitudes orpractices, features that provide

Thorgeir Palsson,Clinical Engineering

Manager in theMedical Service

Departmentat LUH

ICELAND’S ADVANCINGMEDICAL SERVICES

2008 Medical Design Excellence Awardenhanced benefits to the patient, and theability of the product development teamto overcome design and engineering chal-lenges so that the product meets its clini-cal objectives.

The independent jury, with expertise inbiomedical engineering, human factors,industrial design, medicine and diagnos-tics, pronounced: ‘Sectra MicroDoseMammography with its ultra low-doseradiation output and elegant ergonomicsclearly stood out with regard to both thecriteria patient safety and ease-of-use.Aesthetics, while not absolutely critical, isalso important and the elegant Europeanform factor was another positive.’

With two campuses, Iceland’s Landspitali University Hospital (LUH) is the largestmedical institution in Reykjavik. Both are affiliated with the University of Iceland.While LUH is chartered to serve the entire national population of 313,000, its primaryfocus has traditionally been on the 178,000 residents in and near the city. LUH is atthe forefront of specialized healthcare in Iceland, and is the central base forproviding medical services to its citizens as well as educating health professionals.More than 1,100 students are trained at the hospital annually, and nearly all Iceland’sphysicians received their medical education at LUH.

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Fig. 1 Pre-interventional ECG-gated Cardiac CT of a patient with atrial fibrillation scheduled for pulmonary vein isolation demonstrating a separate right middle lobe vein (arrows).The pre-interventional identification of the middle lobe vein has direct implications on the therapeutic success, as it is often difficult to identify this small calibre vein at fluoroscopy.A, B: 3-D volume-rendering reconstruction with different posterior views. C. Virtual angioscopy of the left atrium, view from left side (UL=Vein of upper lobe, LL=vein of lower lobe).

Fig. 2 A. Example of an electro-anatomical reconstruction of the right atrium in a patient with focal right atrial fibrillation.B. The 3-D fusion of an electro-anatomical map of the left atrium with the pre-interventionally acquired 3-D CT data offers theopportunity to increase orientation, safety and efficacy in ablation therapy and to reduce fluoroscopy time and radiation exposure.

For the third in his series of articles for European Hospital, Professor StefanSchönberg of the Institute of Clinical Radiology and Nuclear Medicine (IKRN),University Hospital Mannheim, Medical Faculty of Mannheim, University ofHeidelberg, invited colleagues at the Faculty’s Cardiology and Radiology andNuclear Medicine departments for a round-table discussion on:

Meet the experts Rainer Schimpf1, Radko Krissak2, ChristianWolpert1, Tim Süselbeck1, ThomasHenzler2, Christian Veltmann1, JürgenKuschyk1, Martin Borggrefe1, StefanSchoenberg2, Christian Fink2

1 Department of Medicine-Cardiology and

2 Department of Radiology and NuclearMedicine, University Medical CentreMannheim, University of Heidelberg

Cardiac-CT for guidance ofelectrophysiologic interventions inpatients with cardiac arrhythmiasOver the last decades

invasive cardiac electro-physiologic studies gainedwidespread acceptance for

the diagnosis and treatment ofcardiac arrhythmias. The spectrumof supraventricular and ventriculartachyarrhythmias that can be curedby catheter ablation increasedsignificantly. More complex tachy-arrhythmias such as atrialfibrillation (AF) or atrial tachy-arrhythmias, premature ventricularcontractions (PVC) or ventriculartachycardias in patients withcomplex congenital heart diseasecan nowadays be successfullyapproached.

Electrophysiological studies andablation procedures are currentlyperformed with manually deflect-able catheters under fluoroscopic

effective therapy. Some majordisadvantages are obvious.Frequent fluoroscopy is needed tocontrol catheter movement whichmay lead to substantial radiationexposure time for both, thepatient and physician. The cardiacanatomy is not visible duringconventional procedures.

guidance. The fluoroscopic silhou-ette of the heart, together withexcursions of the catheter duringmanipulation as assessed bydifferent X-ray angulations as wellas the electrical signals recorded bythe distal electrode of the electro-physiologic catheter, are the toolsto localise the target region for an

Therefore, electrical signalsrecorded from the endocardiumby the mapping catheter cannot bedirectly associated to the indiv-idual anatomy in case of conven-tional fluoroscopy.

However, the last decade haswitnessed the development ofhigh-resolution non-fluoroscopicmapping systems and integrationof CT or MRI data sets of cardiacanatomy. The three dimensionalpattern of electrical activationduring the arrhythmia, such asrecurrent PVC or regular supra-ventricular or ventricular tachy-arrhythmias can be reconstructedwith sequential registration of theelectrical activity from differentanatomic regions of the heart.Furthermore, continuous non-fluoroscopic control of the tip of

Rainer Schimpf Radko Krissak

Christian Wolpert Tim Süselbeck

TRENDS IN IMAGE-GUIDED THERAPY

Thomas Henzler Christian Fink

the visualised mapping catheterduring manipulation in the heartchambers is possible. Thus,movement of the catheter can beperformed with less or evenwithout fluoroscopic control.Finally, the new generation electro-anatomical mapping systems offerthe possibility to integrate highresolution cardiac CT or MRIimages in the electrical map of theheart. Prior to the procedure acontrast-enhanced ECG-gated CTof the heart is performed. Thecardiac chamber of interest is thenreconstructed using 3-D post-processing algorithms. Therefore,anatomical variations orabnormalities, which may have asignificant impact on the outcomeof the ablation procedure, e.g.variations of the pulmonary veinsin patients with AF, can be

detected and visualised prior toablation (Figure 1). Afteracquisition of an electro-anatomicalmap during the invasive procedurethe data sets can be merged tovisualise both electrical andspecific anatomic data (Figure 2).However, morphological inform-ation with a preproceduralapproach has the disadvantage thatit does not account for dynamicchanges in anatomical structuresand diameters.

Most recent technologicaldevelopments enable the physicianto steer catheters remote either bymagnetic navigation or by roboticnavigation with a remotelycontrolled flexible guiding sheath.Highly accurate and reproduciblecatheter placement and navigationis mandatory for successful andsustained ablation of the target.The knowledge of the individualand often significantly variableanatomy of the patient is essentialfor a safe and effective therapy.Thus, improved integration ofanatomic CT or MRI data of theindividual patient during electro-physiological procedures offers theopportunity to increase orientation,safety and efficacy in ablationtherapy and to reduce radiation.

UL

LL

A B C

A B

Improved workflow by using ECG-gated CT for guidance of electrophysiologic cardiac interventions


R A D I O L O G Y

The 2nd National Russian Radiology Congress Far more than a national event

Drawing together radiologists from allof Russia is a challenge – even moresurprising is meeting the president ofthe European Congress of Radiology(ECR) and other well-known radiolo-gists from the rest of Europe writesMeike Lerner, of European Hospital,who was at the 2nd National RussianRadiology Congress held in Moscowthis May, to report on the hot topics inradiology over the eastern borders.

‘This year we except 1,500 congressattendees from all over Russia, which isonly possible because we have specialapproval from the Ministry of Health,otherwise colleagues from otherregions could not have participated,’explained Sergey Ternovoi, a fullmember of the Russian Academy ofMedical Science and one of the fourcongress presidents. ‘Last year’s con-gress was very successful and this timewe tried to broaden the congress topicsto include cardiology, pulmonology,urology and some more clinical areas.Our aim is to bring all these specialiststo one round table to discuss the latest

trends, share experiences and of coursetalk about education. In Russia, theterm radiology does not have as abroad a definition as in Europe. In com-mon use, we say Radiology for NuclearMedicine and we distinguish between‘Roentgen’ and Ultrasound. So at thiscongress we invite specialists from allthose specialties to discuss the prob-

The rush to Russia’s booming med-tech marketFor medical technology giants suchas GE, Philips, Siemens and Toshiba,Russia has become a highlypromising market, with the potentialfurther increasing in its growingprivate hospital sector. During theRussian Radiology Congress (26-29May, Moscow) Meike Lerner ofEuropean Hospital met withcompany representatives to discusstheir presence in Russia and anyproblems relating to financing in amarket that has no great experienceof capitalistic structuresAs one of the biggest foreign companies,GE Healthcare has about 200 employeesin cities across Russia and, up to now,has supplied around 5,100 units to over2,900 medical institutions. In 2007, GE´srevenues in Russia/CIS reached US$ 207million, which is expected to more thandouble in 2012. According to Richard diBenedetto, President and CEO of GEHealthcare’s Eastern & Africa GrowthMarkets (EAGM), which includes Russia,this success is based on strong regionalpartnerships that introduce GE´s tech-nologies and solutions, as well as itsfocus on training local medical staff.‘Providing a superb service is one of themost important aspects, if you follow ouraim to provide all parts of Russia withmedical equipment,’ explained SlavaGrischenko, who heads GE Healthcarein Russia. ‘Although our products coverall necessary hospital areas, users needvery good training to benefit from thetechnology. To provide this service weneed to establish strong partnerships inmanpower within the company itself;this wasn’t easy when we began here 20years ago. Today, GE is very well pre-pared for that task.’ For the near futurethe priority is to focus more on the pri-vate patients sector, he pointed out. ‘Themiddle class is growing exceptionallyfast; in just a few years that populationwill be higher than in China.Consequently, demand for healthcarebeyond the basic system will rise.Additionally, compared to the West,Russian health levels are bad: Strokerates are 20 times higher and the aver-age life expectancy for men is about 56years. Russia’s healthcare market faces abacklog, which is a great opportunity forus.’

Richard di Benedetto believes theRussian situation fits neatly in GEHealthcare’s global vision that the futureis about early health. ‘This means movinghealthcare delivery to pre-symptomaticand earlier disease detection. The idea ofinvesting today to avoid ever-increasing

costs in the future is a powerful andinspiring opportunity. Given the socialshift in Russia, we now have the perfectbasis for this strategy because peopleare becoming aware of prevention.’The biggest challenge: knowl-edge distributionFor Joost Leeflang, Philips CEO forRussia, Belarus, Ukraine & Central Asia,the reasons why investing in Russia hasbeen so interesting in the past fiveyears are clear: ‘Russia is an unbeliev-ably large country, with oil producing avery good income and, in general, it hasa highly educated workforce and popu-lation. In addition, the governmentstructure is stable and it aims to providehigh-quality medicine across the coun-try, as well as make it accessible to theentire population. So the government isinvesting huge sums in the nationalproject for public health services. That’sbasically why money is not much of anissue for our customers. So, we don’tface the same problems as in the UK orGermany, for example, which have hugeprivate sectors and where every centmust be turned twice before spending.Of course, that’s something developingin Russia as well, and we expect astrong increase of private hospitals overthe next few years. But, as a provider ofmedical technology equipment, thistrend is another opportunity.’

His colleague Ilya Gipp, who isresponsible for Philip’s CT and MR busi-ness added: ‘In previous years we haveseen the market become more devel-oped and it’s growing. But, for us,development of the infrastructure isalso important. If we install a MR or CTsystem in a more rural hospital an infra-structure must be developed for it to beutilised and to allow a sensible patientthroughput for the system. Consideringthis infrastructure, one big issue inRussia is education. Although the doc-tors’ knowledge is incredible, the coun-try has missed the step to the latestdiagnostic technologies. Besides techni-

cal know-how of the systems, anotherpoint is that Russia has very specialisedhospitals, based on clinical fields suchas oncology or pulmonology. What’simportant to think about in the nearfuture is that equipment must be usedfor various treatment areas, which isonly possible if there is an infrastructureto support that. In a nutshell: The chal-lenge is to ensure there is the rightinfrastructure to maximise the benefit ofour technology. In geographical terms,getting the knowledge distributed is thebiggest challenge.’

For Philips, equipment installationonly begins collaboration with cus-tomers, training and education pro-grammes are integral. The firm haspiloted a CT training programme withMoscow State Medical University, forwhich certification courses were estab-lished.CT and MR scanner sales are upAt Toshiba’s Satellite Symposium on CTand MR, which was held at the con-gress, Dr Jörg Blobel, of ToshibaMedical Systems Corporation, Japan,and Dr Lucia Kroft, from theUniversity Medical Centre, Leiden, theNetherlands, described first experienceswith the Aquilon ONE 320-slice CT.

Audience interest was keen: Toshibahas already sold some of these scannersto customers around the globe andaccording to Mikhail Smirnov,Product Manger for Toshiba MedicalSystems in Moscow, there is more thanone potential customer thinking of apurchase in the near future. ‘We’ve hadgood beginnings with Aquilon ONE inRussia. Along with features such as 4-Ddynamic image acquisition, the optionfor low-dose scanning is of particularinterest. In Russia dose regulations arefar stricter than in Western Europe,’ heexplained. ‘In the last years, Toshiba hasincreased its market share, especially inCT (we hope to number one, now). Inprevious years, a lot of ultrasound sys-tems were installed because they wereaffordable. Now it is CTs turn, becauseits clinical value is much appreciated.With Russia’s growing economy, thenumber of CT scanners and MR systemsbeing installed is increasing tremen-dously.’ However, he emphasised thatentering the private hospital sector is ahuge challenge: ‘Private institutions andhospital networks are created by bigRussian corporations, such as oil andgas firms, which are eager to equipthem with the ultra-modern technology.Our next task is to participate success-fully in that sector.’

TOMOTHERAPY SYSTEM TARGETSCANCER MORE PRECISELY

When tumours are situated in difficultlocations, e.g. near the brain, lungs,prostate or abdomen, patients treatedwith conventional radiation equipmentoften suffer severe side effects, whichinclude bleeding, chronic infections ororgan function limitations. ‘This iswhere tomotherapy opens up newways of therapy and individuallycustomised treatment,’ explainedProfessor Robert Krempien, headof the Radiotherapy Department at theHelios Clinic in Berlin-Buch – amongthe first German hospitals to usetomotherapy against cancer. ‘The newtomotherapy system allows us to treatpatients for whom radiotherapy waspreviously impossible,’ he said.

Worldwide, tomotherapy technology– a combination of linear acceleratorand computed tomography (CT) – isconsidered the most advanced proce-

lems, in the interest of patients.’ International experts such as

Professor Matthias Oudkerk, Headof the European Society of CardiacRadiology, and Professor BorutMarincek, President of the EuropeanCongress of Radiology (ECR) 2009,were also invited, and very pleasedabout the cooperation between Eastand West European countries: ‘Russiaand the East European countries ingeneral are becoming increasinglyimportant, something we’ve noticedjust by looking at the turnout at theECR over the last few years. At themoment, what we can see are differ-ences in imaging technology. In west-ern countries, higher incomes resultedin investments in large medical equip-ment, such as CTs and MRIs, whereasthe eastern countries have mainly usedultrasound scanning. This has not onlyimpacted on costs within the health-care systems, but also on training,which, in Russia for instance, is muchshorter. Understandably, radiologydepartments are interested in harmon-

ising teaching and training, i.e. theywould like to see a convergence of stan-dards from Portugal right across to St.Petersburg. This is, of course, aSisyphean task, as each of the 47European countries has different train-ing regulations.’ Prof. Marincek expectsdevelopments in Russia to take a similarturn to those in the west. ‘There will bea shift away from ultrasound towardsCT, a method that is always repro-ducible. The same goes for MRI. Theacquisition and use of this equipmentobviously always represents a costissue, and Russia’s current situationmeans that this technology is becomingmore widely available in larger cities,whilst rural areas are more or lessexcluded from those developments.’

His colleague Professor ValentinSinitsyn, Radiology Chair at theMoscow State University, Cardiology

Research Complex and a full member ofEuropean Society of Radiology, pointedout another problem related to the shiftto CT and MR: ‘Our government hasdeclared a national health service pro-ject and provides money for hospitalsfor refurnishing and construction. Butone problem that remains unsolved isservicing the equipment. The moneydonated to the hospitals is not enoughfor equipment maintenance. Sometimesthe situation is paradoxical, because it’seasier to send an application for a newmachine than it is to repair a systemthat is four or five years old.

‘Another problem we face is teaching.If you look at the statistics, we havemany radiologists, but the number ofthem who are active and able to workefficiently with modern equipment isnot that high. So we need more spe-cialised training and I agree with ProfMarincek that education has to becomemore equal across Europe.’

dure in radiation therapy. Whilst a highresolution CT precisely locates atumour, before each individual radia-tion dose, the linear accelerator, rotat-ing around a patient, fires at a tumourfrom all sides. ‘We protect sensitiveorgans by radiating the tumour frommany different directions and avoidingthese sensitive organs,’ Prof. Krempienpoints out. In addition, the radiationdose that destroys a tumour can beindividually customised to thetumour’s density (the number of cancercells).

The tomotherapy system alsoenables radiation of several tumoursand metastases in one day. Adjustingthe radiation dose intensity to theextent, strength and type of tumourpresents even better protection ofhealthy tissue and neighbouringorgans. Depending on the tumour, radi-ation lasts 5-20 minutes.

Additionally, although the locationof organs and tumours change contin-uously, tomotherapy adapts to thosechanges during radiation. The equip-ment captures slices indicating thecurrent size and location of a tumourwith the integrated CT prior to eachradiation, so the beams can preciselyreach organs that move.

RobertKrempien andtomotherapysystem

Left: Borut Marincek,Director at the Institutefor Diagnostic Radiology,University Hospital Zurichand President of theEuropean Congress ofRadiology 2009

Right: Valentin Sinitsyn,Moscow StateUniversity CardiologyResearch Complex

Left: Sergey Ternovoi,Full member of theRussian Academy ofMedical Science andone of the fourcongress presidents

Richard di Benedetto Slava Grischenko

Joost Leeflang Ilya Gipp


R A D I O L O G Y

In the 30 years since the overthrow ofits last Shah (1979) Iranian radiologistshave been welcome speakers andresearch presenters at the EuropeanCongress of Radiology (ECR). This year,the Iranian Society of Radiology, whichrepresents over 2,000 radiologists, alsointroduced itself at the congress. Therethe latest issue of the Society’s officialradiology journal, the Iranian Journal ofRadiology (also in English) was also dis-tributed, along with previously pub-lished issues and the Society’s journalon general medicine.A R Sedaghat MD (pictured right),Head of the Iranian Society ofRadiology (ISR), not only presented theSociety’s work but also congeniallyinvited fellow radiologists to visit Iran.Speaking with Daniela Zimmermann(left) of European Hospital, heexplained that the Society is run in tan-dem with the North American IranianRadiologists Society (NAIRS). Memberswho are internationally famous special-ists include Dr Mahmood Mafi (headand neck); Dr Khalkhali (mammogra-phy); Dr Azarkia (central nervous sys-tem) and Dr Bonakdarpoor (MSK).Over 1,000 radiologists and interna-tional experts attend the ISR annualcongresses. In 2007, the Society alsoheld its first conference on informaticsin radiology. Speakers included DrHuwang (very famous in PACS, DrSedaghat pointed out). He emphasised

Successful therapy for uterinefibroids using MRgFUS Magnetic Resonance Guided Focused Ultrasound (MRgFUS) therapy wasintroduced in June at the Amperklinikum in Dachau, near Munich, thethird German site, after Berlin and Bochum for this new technology.Dr Matthias Matzko, Head of Radiology at the Dachau Clinic andProfessor Gerlinde Debus, Head of its Gynaecology Department,presented the advantages of this non-invasive ablation procedure foruterine fibroids. Bernd von Polheim, President of GE HealthcareGermany and Dr Dov Maor, Vice President Clinical Marketing InSightec,representing the two companies involved in the technical development,were also at the press presentation.

MRgFUS, explained Bernd vonPolheim, is a particularly gentle pro-cedure. ‘Combining focused ultra-sound therapy with MRI enables pin-point accuracy. Real-time efficiencymonitoring via thermosensitivesequences facilitates exact position-ing with pinpoint accuracy alongwith permanent monitoring of thetemperature distribution in the ultra-sonic beam. The surrounding tissueis not damaged by heat and thefibroid is literally melted off throughthe release of energy. Moreover, theprocedure replaces surgery, thepatient is not exposed to radiation,there is no need for anaesthetic andthe patient can be discharged thesame day. In addition the therapy ispainless.’

Fibroids are benign and thereforenon-hazardous muscle tumours;however, depending on size andlocation they can cause substantialproblems, or prevent pregnancy.Current studies show that patientsundergoing MRgFUS have the bestchances to have fibroids removedwithout impairing fertility. As manywomen want fibroids removed,because they hope to become preg-nant, the Dachau Clinic has decidedto offer MRgFUS as an alternative tominimally invasive surgery, such asfibroid embolisation.

‘The procedure is really fascinat-ing and has great potential,’ said DrMatzko. ‘Fibroid therapy is only thebeginning. We’d like to be to thefore with this application and fur-ther developments from the start.We also hope to treat other diseases,e.g. breast cancer, for which thereare already some phase II therapystudies in other hospitals, whichhave shown malignant breasttumours up to 1.5cm can be meltedoff with focused ultrasound.’

Is fibroid size significant usingMRgFUS?‘Unlike malignant breast tumours, inthe uterus we can treat fibroids ofany size, but this must be done overseveral sessions. Two factors aredecisive for the success of non-inva-

can repeatedly redirect the US ener-gy right on the fibroid. Moreover,during the planning stage we putland markers within the fibroid andexclude the critical structures priorto commencing treatment. However,it is not a problem to interrupt atherapy session, and then carry onin a second session if there is a lotof fibroid tissue, or if the patientrequests it. THE FUTURE OF MRgFUS‘We’ll be better than surgery’Dr Dov Maor is one of the foundersof InSightec, a subsidiary of GEHealthcare. AsVice President forClinical Marketing, he develops andpresents the new MRgFUS and itsclinical applications to Europeanmedical and academic communities.

Seeing that MRgFUS is alreadysuccessful in the treatment offibroids, we asked him what otheruse he foresees for this technology.‘Initially, we began our work withbreast cancer research. As physi-cists and engineers, we assumedthat the breast would be easy totreat because the tissue is soft andeasily accessible. Then it transpiredthat this is not the case. Moreover, itwas very difficult to carry out stud-ies in this field, which would con-firm that malignant tumours can

Highlights of the Iranian Society of Radiologythat there are no visa problems for sci-entific meetings. ‘We have not closedour gates against other countries. Weknow a lot about them -- European,South American, as well as Canada andthe USA, but I think the media in theWest has closed a lot of windows, sopeople don’t know a lot about us.Today, a lot of tourists visit as well asforeign doctors, scientists and engi-neers, to work here. Today, I can callmy country the land of peace,because Afghanistan has war, Iraq haswar, the countries of the former SovietUnion are not as economically stable,and some of the Gulf countries are verysmall and don’t want to fight againstIran (KSA is the biggest). KSA is the cen-tre of Islamic pilgrims (Mecca andMedina); at no time would they fightagainst an Islamic country. So every-thing is very peaceful.The way to help a country to advanceand grow is not to put money in peo-ple’s pockets, he said, but by showingthem the way to grow by investing themain budget into the economy of thecountry. ‘We have a lot of very big elec-tricity sources, which produce over40,000 megawatts of electricity, whichwe export to neighbouring regions,such as Iraq.Also, before the revolution,we had only 11 medical colleges. Nowwe have 40. Imagine! We also havemany highways, bridges, and airports invarious cities. Money from gas and oil

in those 30 years was mostly spent inthis way. So, though not all the people,but most of the people agree with thegovernment. At the big annual gather-ings in our cities celebration the revolu-tion, in Tehran alone, there were morethan one million people in the streetsthis year. The President talked withmany, and the event was directlyreported by 50 TV companies.’ The argu-ments with the USA, he explained,relate to some $20 billion held inAmerican banks, since ‘the time of KingPahlavi, the Shah’.Dr Sedaghat is no stranger to the ECR,or Austria. He has participated fivetimes, and taken a week-long MRIcourse there. His main focus is on neu-roradiology and muscular skeletal radi-ology. Additionally, his own radiologypractice in Karaj, near Tehran, is thecountry’s biggest private clinic (over400 patients daily). There the day startsat 8 am, often ending at midnight. Itprovides offers nuclear medicine andechocardiography, MRI, digital mam-mography, CT scan, BMD, US, digital

be removed non-invasively. Surgicaltreatment procedures for breast can-cer in its early stages have alreadybeen established. It’s a long waytocertification of our procedure.However, we remain convinced thatwe will be able not only to avoidsurgery but also be better thansurgery. Whereas a surgeon cannotdifferentiate between tumour tissueand healthy tissue during an inter-vention, we can trace a tumour’soutline very precisely using MRIduring a procedure. This saves timeand drawn-out follow-up treatment.

‘Our next big project will be thetherapeutic treatment of metastasis-ing or primary liver cancer. Here weface completely new technologicalchallenges – first, the liver movesposition during breathing and sec-ond, it is largely obscured by theribs. In most patients, the liver can-cer is situated under the bone.That’s why we are working on thedevelopment of a special applicatorthat can aim between the ribs. Wehope to start clinical trials for this inabout 18 months. We also hope touse the same method for the treat-ment of kidney tumours, or maybeeven pancreatic tumours.

‘We have already gathered promis-ing results from our procedure for

the palliative treatment of bonemetastases, and received theEuropean licence last year.Although bones are not made ofsoft tissue, which can be focusedon as precisely as our other tar-gets, we have been working on astrategy for years to replace radia-tion with MRgFUS. Radiation isonly successful in around 70% ofcancer patients in advanced stagesof cancer and has strong sideeffects. We’d like to offer proce-dures for the palliative treatment ofpain that put less strain on thebody, particularly for patients withadvanced stage cancer

‘Additionally, we are currentlyresearching the use of MRgFUS totreat brain problems. This not onlyfocuses on oncological treatment,but also on central nervous systemproblems, e.g. epilepsy. Sometimesit suffices to destroy just the small-est pieces of brain tissue to rectifymalfunctions. This is why we’vedeveloped equipment that allowsus to focus on the brain throughthe intact skull. We are working incooperation with the Neurosurgeryand Neuroradiology Departmentsof the Brigham and Women’sHospital, Harvard University, andUniversity Hospital Zurich, where-doctors have already identifiedcentres in the brain responsible forcertain functions. Last month theyreceived clearance from the EthicsCommission to treat the firstpatients.

‘The potential of MRI guidedFocused Ultrasound is far fromexhausted,’ he concluded.‘However, the developmentprocesses for these systems arelong and it’s a long way from atechnological concept to clinicalapplication!’

radiology, OPG etc, and employs eightradiologists, seven cardiologists, twonuclear medicine specialists and twogeneral practitioners (both women),who compile patients’ physical exami-nation results and clinical history, help-ing the radiologists to write reports andmake diagnoses.Dr Sedaghat is in his second term as ISRpresident for four years. He explainedthat such elections are monitored by theMinistry of Health as well as theMinistry of Internal Affairs. ‘We haveover 85 medical scientific associationsin Iran, of which the radiologists’ societyis among the five biggest societies inthe country.’ It not only focuses on radi-ology as a science, but also is responsi-ble for fee setting for various treat-ments. ‘Up to two years ago, the latterwas the responsibility of the Ministry ofHealth; now this task is undertaken bymedical associations and Iran’s MedicalCouncil,’ he explained. (All medicalgraduates, including midwives, etc.must be registered with the MedicalCouncil, which has about 170,000members). ‘So, part of our responsibilityis to set the annual radiology fees,which depends on Iran’s budget. Wehave to increase our fees proportionallyto the increased budget rates. But ourmost important responsibilities are sci-entific. We hold many small, local con-ferences annually, around the country.We also have central and annual con-

gresses, e.g. the Iranian Congress ofRadiology (ICR) and, since 2007, theCongress for Informatics in Radiology.We also hold workshops, for exampleon CT, ultrasound and GI, chest etc.and take a very active part in interven-tional radiology, for embolisation infibroid tumours in the uterus, aneuris-mal treatment, RF ablation of tumoursand so on, and have published manyarticles on these in our journals. Wework, for example, with gynaecolo-gists: the radiologist embolises atumour to minimise its size anddecrease blood flow; the next day, thesurgeon operates on it.’ This area seesconsiderable cooperation with special-ists beyond Iran, he added.. ‘Tehranhas ten 64 slice multi-detector CTscanners and more than 80 MRImachines; most are 1.5T machines --Philips, GE, Siemens – and smallermachines, 0.3T, come from Japan.In three decades, improvement andprogression in Iranians lives has beenvery good, he said: ‘I’m 49. I rememberwhen the revolution began. At 18years old, in my first year at TehranUniversity of Medical Sciences -- over85% of our villages had no electricity,clean water, or good environment.Now, more than 95% of villages haveelectricity, clean water, schools, andvery good environments. I invite you tocome and see one of the most beauti-ful countries (IRAN).’

sive fibroid therapy: location andnumber of vessels in the fibroid.’He continued. ‘If the growth is toosaturated with vessels, the bloodvessels act as cooling aggregatesand heat around our focus point isabsorbed. In this case, we can offera patient hormone therapy prior toultrasound therapy, to decrease thevessels in the fibroid. We combinethe procedures because fibroidsonly decrease while hormone thera-py is given, then they grow back.

‘The second factor: We cannotablate if the position of a fibroidmeans that the ultrasound beamgoes through critical structures,such as the intestine. The danger ofburning is too great, as tempera-tures of 60-80 degrees are reachedafter only a few seconds.

Therapy for a medium-sizefibroid takes 2-3 hours. What of thestrain on a patient who must notmove in the MR machine? Thepatient has a light sedation andpain killers, making lying morecomfortable. As long as she doesn’tmove much, nothing can happen.The MR image shows us with adelay of only three seconds what ishappening in the body at any giventime. Both systems are fine-tunedto each other so precisely that we

Dov Maor

Matthias Matzko (left) with Gerlinde Debus

In today’s clinicallaboratory thetechnical staff per-forms quality in-spections that areseparate and dis-tinct from normallaboratory testingquality control.

These inspections include checkingif the specimen type is correct forthe ordered test or at the correcttemperature, verifying that it isfrom the correct patient by com-paring the doctor’s office label tothe laboratory’s label, or inspectingspecimens for clots, fibrin, haemol-ysis, icterus, or lipaemia. Systemsthat have been used in industrialsettings for the past two decadesare now starting to make their wayinto clinical laboratory automation.Generally known as machine

vision, this is a group of technolo-gies that can replace human inspec-tion.

Practically every product youpurchase today is assembled andpackaged with greater efficiencyand quality due to machine visiontechnology. In pharmaceuticalplants, sophisticated optical sys-tems inspect bottles on conveyorsto ensure labels are straight andcap seals uniform and tight. Theyread lot numbers and expirationdates, comparing them to what isexpected, and assure there are nored pills in bottles of white pills. Inbreweries, wineries, and other bot-tling plants, machines check fill lev-els, rejecting under-filled cans orbottles on conveyors at speeds 50-100 times faster than today’s fastest

Work procedures have been radical-ly simplified since, over one week-end five years ago, two specialistlaboratories owned by Dr HelgeRiegel GmbH Medical Supply Centrein Wiesbaden, Germany, installedtwo Olympus OLA2500 systems.‘The goal was to have one system inroutine operation by the Monday.However, we were actually able toput both to work immediately!’exclaimed Dr Patrik Zickgraf, spe-cialist at the Centre’s clinical labora-tory.

The clinical medicine laboratoryserves around 1,100 registered doc-tors and processes about 5,000 sam-ples a day – roughly five million ana-lytical tests each year.

‘The new laboratory electronicdata processing system led tochanges in our existing procedures,including the introduction of bar-code labelling,’ Dr Zickgraf told us.‘Our laboratory archives sampletubes for four weeks. Previously wewould record the procedure andthen divide the samples broadly bydepartments. Sub-division was per-formed manually with final distribu-tion to different analytical worksta-tions performed only after this stage.This distribution of samples in thespecialist medical laboratory is verycomplex, resulting in the risk ofsample mix up; confusion during


L A B O R A T O R Y & P H A R M A C E U T I C A L S

Lean Laboratory and Lean Auto-mation are vital ingredients for theefficient and productive running oftoday’s modern pathology laborato-ries. Automation serves as an essen-tial endorsement to Lean, says Paul M Button, Senior Consultant at ValuMetrix, Ortho ClinicalDiagnostics*

The underlying principle of Lean – tochange the culture, create flow and elim-inate waste in all its forms – is logical andreadily understandable. It should be nosurprise that Lean process improvementis the methodology of choice for the UK’sNational Health Service (NHS).Considering its outcomes, it is clear that ifLean were a piece of equipment, everylaboratory manager would buy one. ButLean is not a piece of equipment; it is afundamental change in working practicesand the thinking behind them. It is anattitude of mind, which constantly seeksto challenge and refine every aspect ofworking life. It is proven to work, but itcan also hurt.

Established practices are demolished inthe search for culture change, flow cre-ation and waste elimination. Batch work-ing and specialisation go out; single pieceflow and cross training enter. Laboratoryworkers who are desperate for morespace, discover they can work better withsignificantly less. Managers can discoverthe factors that really impact on theirworkflow; biochemists walk less as Leanprocesses improve laboratory layout.

Johnson & Johnson’s ValuMetrixServices group first made its ProcessExcellence methodologies, which includeLean, available to healthcare organisa-tions in 1999. Its proven success is basedon a training and mentoring model thatrecognises that culture change should notbe imposed and that communicationsand commitment lie at the heart of anysuccessful project. Unlike many consul-tancy or change management processes,ValuMetrix actually sets out to transferintellectual capital and knowledge to theclient organisation, so that future processimprovement projects can be run frominternal resources.

The majority of laboratories would ben-efit from automation, but this should notbe incorporated until after lean imple-mentation. Automating a non-Leanprocess will result in ‘automating waste’,which is very difficult to rectify. Achievingan efficient flow is usually impossiblewithout some level of automation. Thekey is to achieve the right level. Too littlemeans lost efficiency; too much meanslost reliability and affordability.

ValuMetrix Services offer a combinedLean and Automation approach, wherebythe initial phase ensures that the labimplements Lean principles followed bysubsequent phases that implementautomation at appropriate points in theoperations. This is done by a Lean tech-nique known as Value Stream Mapping,which moves the lab from the currentstate through a series of future states toachieve an ideal, world-class laboratory.

The results can be astronomical withsubstantial reductions in turn-around-times, substantial reductions in error, sub-stantial cost savings and significantincreases in productivity thereby allowingbusiness growth without staff increase.

Further details can be obtained viayour local Ortho Clinical Diagnosticsoffice.* A Johnson & Johnson Company

Automation: a five-year experience

Machine vision technologiesA group of technologies that canreplace human inspection areentering the clinical arena, writesCharles D Hawker PhD MBA FACB,Scientific Director of Automationand Special Projects at ARUPLaboratories and AssociateProfessor of Pathology (Adjunct),University of Utah School ofMedicine in Salt Lake City

accepting anddistribution; diffi-culties in trace-ability and a highconsumption ofmaterials durings u b - d i v i s i o n .Since we havemany worksta-tions, the flow of

samples around the laboratory wasnot optimised. This all highlightedour need for automation.

‘The OLA2500 was the only sys-tem that covered all our require-ments – indeed it still does. It isstraightforward and practical.Thanks to the automatic archivingwe can now quickly locate sam-ples, traceability is always ensured;we can document and trace thepath of the sample from intake upto archiving. We have also reducedturnaround time (TAT) within thelaboratory due to enhanced perfor-mance in distribution, processingand archiving.

‘Finally,’ he added, ‘we haveexperienced a significant reductionin serum consumption, since auto-matic sub-division takes only thevolume that is actually required.The OLA systems have given usmore time to ensure the quality ofour analytical work and alsoenabled us to redeploy staff from

laboratory automation conveyors.Depending on the particular plant,

fill levels are checked by weight, withgamma rays or X-rays, or other sys-tems. Other systems make sure thereare no glass shards in jars of mar-malade. The list is endless. These vir-tually 100% accurate, high speedinspections are simply not possiblewith human inspectors.

Laboratory automation manufac-turers are beginning to employmachine vision to improve qualityand replace human inspection. Someoptical systems inspect tubes for capcolour, height, and diameter. Someinspect through the open side of atube (if it is not completely coveredwith a label) and determine presenceand degree of haemolysis, lipaemia,or icterus. At least two systems can‘peer’ through the labels on a closedtube, determine the height of packedred cells, and calculate the volume ofserum or plasma above the cells. Thisinformation can be used to verify cor-rectness of the specimen for anordered test, prompt a report com-ment, or set aside the tube for manu-al intervention. The latter step ismore valuable than it sounds. If 95%of tubes pass an automated inspec-tion, then the technologist only has tohandle 5% instead of 100% to deter-mine the next step.

Two decades after automobileassembly plants and other manufac-turers began to use automationrobotics, Japanese laboratoriansbegan to apply automation concepts,but it was another decade beforeearly Japanese automation ideas forclinical laboratories appeared in sys-tems from laboratory equipment ven-dors. Similarly, machine vision sys-tems have now been in place in indus-trial settings for at least two decades,although much faster and moresophisticated today than in the earlyyears. Nevertheless, it seems interest-ing to this observer that, once again,the clinical laboratory is roughly 20years behind in applying industrialtechnologies that could have realvalue in the laboratory setting.

distribution/archiving work to othermore productive tasks.’

The Centre’s two machines areoverseen by just one staff member.How has the equipment affected thelab teams? ‘Staff acceptance is highbecause the reliability and robust-ness of the OLA2500 systems is soimmense; even if a very infrequentfault does stop the system, it cangenerally be rectified immediatelyby our experienced staff,’ DrZickgraf pointed out. ‘When theneed arises, the excellent training ofthe Olympus service engineers hasbrought the machines back into ser-

vice the very same day. TheOLA2500 is a successful system; it’smade relaxed operation possible,’he added.

‘We now have five years experi-ence with laboratory automation,providing us with a very clear andtransparent workflow. This trans-parency, and the fact that the labo-ratory staff can see for themselvesthe advantages that the systembrings, generates acceptance. Thisalso allows us to continually opti-mise our work procedures. Aboveall, it is essential that everyoneunderstands the ‘‘path taken by thesample tube’’. Only then can theygrasp the benefits delivered byautomation.’

Leanprinciplesappliedin path labs

Charles D Hawker

Paul M Button

Dr Patrik Zickgraf



Having attended this event for nearly20 years, Mike Hallworth (below),Consultant Clinical Scientist at theRoyal Shrewsbury Hospital, UK, andPresident of the European Federation ofClinical Chemistry and LaboratoryMedicine, agrees with Dr. Plebani: ‘TheAACC Meeting is unquestionably themajor annual event in global laboratorymedicine, delivering unrivallednetworking opportunities, a world-classexhibition with everything that issignificant in laboratory diagnostics,and a scientific programme withsomething for everyone and some trulyexcellent plenary lectures. After almost60 years, it continues to develop itspre-eminent position in our disciplineand provides laboratorymedicine professionalswith a consistentlyrewarding experience.’2008 AACC details:http://www.aacc.org/events/ann_meet/Pages/default.aspx

21st Century lab automationDavid Loshak outlines the impact of rapidly increasing mechanisation on the work of hospital lab technicians, researchers and industryLaboratory automation of the 21stcentury demonstrates, every second,that in the 30 years since labs tooktheir first tentative steps towardsautomation it has advanced by ordersof magnitude – and moved farbeyond the ambitions of its progeni-tors. Driven by the imperatives ofgreater efficiency, more precisionand round-the-clock operation, evermore sophisticated forms of automa-tion are now widely applied in dis-covering new medicines, enhancingproductivity, reducing error, acceler-ating research, standardisingprocesses, improving safety.

Innovations in robotics and infor-mation technology have transformedresearch. In the search for new med-icines, automated laboratories userobots to manipulate, store andretrieve titre plates; in cell culturingand pharmaceutical research, theyundertake specialised forms of mate-rial handling with the loading andunloading of test tubes in autoclavesas well as liquid-filled vials, flasksand bottles. Robots in hospitals fillprescriptions, improve the securityof pharmaceuticals and reduce mis-takes in preparing prescriptions.

Automation also helps to meetstringent demands for rapid patienttesting without compromising safety– the laboratory staff has minimalcontact with specimens. Tests thatrequire 17 steps in conventional labo-ratories take nine with system-basedautomation, five with discreteautomation and three with integratedautomation. Laboratory directors canjustifiably claim that at least threequarters of clinical decisions hingeon good lab information. ‘And we

have eliminated the unpredictabilityof our lab service,’ adds Dr KennethBlick, director of clinical oncology atOklahoma University MedicalCentre. ‘We have gone from 18% out-liers on our turnaround time targetsto less than 5%.’

An iconic instance of modern lab-oratory automation is provided byliquid handling, a key to drug discov-ery because most experiment entailsdefinite volumes of reagents.Handling low volumes, calibration,integration and liquid detection arekey features of automated liquidhandling systems. Hand-heldautomation devices, such as singleand multi-channel pipettes, havehugely affected lab productivitybecause they permit dispensing intomicrotitre plates, or microplates, thestandard tool in analytical researchand clinical diagnostic testing, bestknown for its use in the enzyme-linked immunosorbent assay(ELISA), the basis of most modernmedical diagnostic testing.

Efficient automated liquid han-dling systems have led directly tominiaturisation of assays. Today’sdrug discovery is based on HTS –high-throughput screening – whichuses robotics, data processing, liquidhandling devices and sensitive detec-tors so that researchers can conductmillions of biochemical, genetic andpharmacological tests that rapidlyidentify active compounds, antibod-ies or genes that modulate particularbiomolecular pathways.

‘The ability to do half a million testpoints in only one day has openedup new strategies in exploringdrugs,’ says Kevin Hrusovsky, CEOof the US corporation Caliper LifeSciences. He notes that becauseplate formats can lower the volumesof samples needed to sub-microlitreamounts, the cost of reagents ismuch less. Although moving andmeasuring small quantities of fluidspresents challenges, automated liq-uid handling does allow precisemeasurement of amounts as little asone nanolitre (a hundred millionthof a litre). ‘That not only permits sci-entists to use tiny quantities butmeans that fewer repeat tests areneeded because the equipment con-firms when the right quantities aredispensed.’

The results of such experimentsprovide starting points for drugdesign and for understanding theinteraction or role of particular bio-chemical processes. Followinggenome sequencing and the emer-gence of genomics, life scientistshave developed proteomics, the newscience of the complex structures ofliving cells and how they function.This has disclosed huge numbers ofnew targets which have potential asdrugs, far too many for researchersto study with old manual methods.Thus, HTS has become a key ele-ment in modern drug discovery. Nowonder the laboratory automationequipment market in Europe aloneis now worth some €200 million.

Possibilities to co-develop new clinical diagnostic tests for companiondiagnostics, metabolic syndrome, oncology and diabetes, are being explored bySiemens Healthcare and Laboratory Corporation of America Holdings (LabCorp).

Companion diagnostics are tests designed to identify the suitability betweenpatients and a particular drug therapy. The tests can be used in personalisedmedicine to improve the safety and efficacy of therapeutic drugs and in somecases, may help determine optimal dosing for individual patients.

Metabolic syndrome is becoming more common and is characterised by aperson having multiple risk factors that may include high blood pressure, heartdisease, obesity and diabetes, among others. It is estimated that more than 50million people are affected by this syndrome in the USA alone.

LabCorp is a reference laboratory with over 220,000 clients in the US. The newstrategic cooperation, said Dave Hickey, Senior Vice President Strategic Planningand Business Development, Siemens Healthcare Diagnostics, ‘establishes aframework that gives both companies the opportunity to offer new diagnostictests to laboratories, physicians and their patients more quickly and effectivelythan either could do alone.’

Myla P Lai-Goldman MD, executive vice president, chief scientific officer andmedical director for LabCorp, added that the firm is ‘… excited about thisstrategic collaboration and its impact on our companion diagnostics efforts.Alliances, such as this between developers and providers of new tests, arecritical in translating emerging biomarkers from research into clinical practice.’

Siemens Healthcare Diagnostics will showcase thecombined strengths of Diagnostics Products Corporation(DPC), Bayer HealthCare Diagnostics and Dade Behring.

As a leading global clinical diagnostic company, Siemens will demonstrate itswide portfolio of workflow solutions and customer-centred services for today’slaboratories. These products include automation, chemistry, immuno-assay,haemostasis, haematology, microbiology, molecular, blood gas, urinalysis,diabetes, IT and customer care.

AACC/ASCLS Clinical Lab Expo

Effective HTS relies on efficientinformation management systemsto deal with the data it generates.‘Typical large pharmas today aregenerating 20 terabytes of datadaily and that will soon rise to 100terabytes,’ according to JohnHelfrich of Massachusetts-basedNuGenesis Technologies Corp-oration. A good data system, heexplains, handles the capturing,loading, sorting, querying and view-ing of information from both bio-logical and chemical perspectivesand also needs the flexibility toscale up with increasing HTScapacities. ‘Our scientific data man-agement system is an application-independent, web-enabled plat-form for collecting, storing andmanaging scientific information.The system captures the essence ofreports,’ he adds. ‘We put a printdriver on the instruments and cap-ture the contents of their informa-tion. The value of that is that it isinformation source independent. Ascientist does not need mass spec-trometry or chromatographic soft-ware to capture the data from thoseinstruments. Any scientist at thelab bench who has securityapproval can look at those reports,extract what he or she needs fromthem and send them on.’ The sys-tem thus fosters high levels ofteamwork and drives up the pace ofdecision-making in many areas ofdrug R&D.

Although there are laboratories

that still need to work out how bestto use automation most efficiently,such problems are minor comparedto the potential of lab automation,declares Tony Beugelsdijk, chair-man of America’s Association ofLaboratory Automation. ‘Integratedlibrary management is comingalong – we will probably see for-mats that enable libraries tobecome part of an HTS system,miniaturised beyond what we seetoday.’ The results of screeningenabled by lab automation wouldbecome available to more scientiststhan in the past. Manual scoring ofcrystallisation experiment imageswould be replaced by computation-al scoring.

Indeed, the automation of X-raycrystallography provides a para-digm of how laboratory automationevolves.

First come efforts to automatemanual procedures. While theseoften work well, they do not alwaystranslate well enough, so processesare re-engineered to take betteradvantage of automation. Then,other snags and challenges emergeand are addressed.

But the bottom line, asAmericans, who lead the world inlaboratory automation are fond ofsaying, is that lab automationincreasingly gives scientists authen-tic freedom. ‘Scientists do sciencebest; instrument companies doinstruments,’ says Joan Stevens, ofGilson Inc. of Wisconsin, US, mak-ers of automation instrumentationand chromatography systems.‘Together, we make a very nicepackage.’

A variety of 15-minute presentationswill be conducted in the Siemensbooth, including:● Monitoring Metastatic Breast

Cancer: The Serum HER-2/neu Test● Paediatric Allergy and Asthma● Sepsis: ‘Can Emerging Markers

Improve Survival Rates?’● MRSA and Beyond● Liver Disease: Evolving

Perspectives on Diagnosis andManagement

● Point of Care Testing

30 July: Educational workshops● Trends in Immunosuppressive Drug

Use and Cost Effective Monitoring ofImmunosuppressive Drugs at theLocal Community Level

● High Sensitivity Troponin: DeliveringValue for Chest Pain Management

● Trends in Infectious Disease Testing:A Conversion of Technologies to Meetthe Emerging Threat

● The A, B, C’s of In Vitro Allergy Testing ● Non-Invasive Markers of Liver Fibrosis

– Why are they Needed?

Why European laboratorians benefitfrom the AACC Annual Meeting

By Mario Plebani MD (left), Professor of ClinicalBiochemistry and Clinical Molecular Biology at theUniversity of Padova, Italy, and winner of the AACC’sOutstanding Clinical Laboratory Contributions toImproving Patient Safety Award, to be presented atAmerican Association for Clinical Chemistry’s 2008Annual Meeting to be in Washington, DC (27-31 July)

“When asked to write a brief note onwhy I found it ‘important to attend theAACC Annual Meeting, particularlyfrom the European perspective’, mymind returned to the first time I attend-ed an AACC meeting. It was in NewYork, and provided my first opportunityto visit the USA. I was very excited atthe idea of seeing the ‘New World’ andthe ‘Big Apple’ and, of course, attend-ing a scientific event organised by themost influential scientific society forclinical chemistry worldwide.

My expectations were amply met,and I greatly admired the outstandingCongress organisation, despite theincredible number of delegates. I wasalso impressed by the high standard ofthe scientific sessions and quality ofpresentations, many of which weredelivered by ‘icons’ of modern medi-cine, such as J D Watson (1962 NobelPrize in Physiology or Medicine for dis-coveries on the molecular structure ofnucleic acids). Another aspect that Iappreciated was the time dedicated todiscussing all the presentations and thequality of these discussions. At thePoster session, I was particularlyimpressed by the high level of scientif-ic discussion and the exchange of ideasthat took place in front of each poster.This was, and still is, quite unusual inItaly and other European countries.However, I confess that I was really sur-prised to learn that seminars and scien-tific presentations would take place at7.00 a.m., and was shocked to seethese being made while people werehaving breakfast!

Throughout the years my reasons forattending the AACC Annual Meetinghave changed, but some fundamentalpoints remain. First, the plenary ses-sions provide a unique opportunity tolook at the future not only of the disci-pline but, more importantly, of health-care systems and the global environ-ment in which laboratory services

are delivered. The Symposia andInteractive workshops (although I pre-fer to remember the ‘Edu-Tracks’) havealways been interesting, but have alsocontributed to changing the delivery of

always interesting, with its display ofequipment, diagnostic systems andlaboratory devices, but its importanceto an ‘old’ laboratory professionallike me has, in a way, decreased overtime because there are always otheropportunities to see and ‘touch’ inno-vative systems. However, it remainsan important attraction and meetingpoint, particularly for people attend-ing this event for the first time. Frommy perspective, however, the impor-tance of attend the AACC Congresshas increased, since it provides aunique opportunity to meet many sci-entists and colleagues from differentcountries. In an era of globalisation,the ‘de visu’ exchange of ideas andexperiences is becoming increasinglyimportant, and this meeting is, andwill remain, a unique opportunity, asdemonstrated by the number ofmeetings of the Scientific Boards ofjournals and organisations that occuryear by year, before, during and afterthe AACC Meeting itself.

Let me conclude with another per-sonal anecdote. The first time I wasinvited to deliver a lecture in a ses-sion of this meeting, I had mixed feel-ings, because there was no way ofescaping criticism – or low scores inquestionnaires completed by partici-pants! Although I felt honoured to beinvited, I was not that open to criti-cism. ‘The world is flat’– of this weare sure and there is no doubt aboutthis – but there are still many goodreasons for European laboratorians,including Italians like me, to continueto attend the AACC Annual Meeting!”

laboratory services. For example, thestory of cardiac markers is a paradigmof the change and improvements thatlaboratory medicine has brought in themanagement of acute coronary syn-drome.

The Exposition, on the other hand, is

Siemens – special events at Booth #507Washington DC 29-30 July 2008

In addition, Siemens will sponsor five AACC awards forexcellence and over 37 scientific posters throughout the week.Full details: www.siemens.com/AACC2008.

AACC27-31 July 2008Washington DC

Companion diagnostics and moreSiemens and LabCorp to co-develop clinical tests

High throughputsequencing technologyenables analysisof protectiveintestinal florathat couldcombatClostridiumdifficile



Italy – The genome sequence of Acinetobacter baumannii has beendetermined by scientists at the Istituto di Tecnologie Biomediche, theDipartimento di Malattie Infettive at the Istituto Superiore dellaSanità and the Dipartimento di Biologia at Roma Tre University. InItaly alone this antibiotic resistant pathogen causes 4,500 to 7,000deaths annually.

Genome sequencing is the foundation for rapid diagnosis andtargeted therapy approaches, said project manager Gianluca deBellis. ‘Sequencing was made possible by a further improvedtechnique which can generate more than 100 million DNA baseswithin a few hours. This translates into a significant time and costadvantage over the previous methods.’ Using this sequencingmethod the Italian scientists hope to identify new substances for thedevelopment of new antibiotics. The phenomenon of antibioticresistance will be examined from a basic and applied research angle.This genetic sequence is available free, via www.itb.cnr.it/genome-project.

KNOW YOUR ENEMY

Christoph Högenauer

Along with MRSA and ESBLbacteria, Clostridium diffi-cile is causing a growingproblem. Epidemics of a

new C. difficile strain have alreadyoccurred in hospitals in NorthAmerica, England and the Beneluxcountries. Although in its inactivestate it is not harmful to humans,C. difficile can abruptly proliferatein the gut if the protective flora isdisturbed due to antibiotic therapy;and then the toxins released by C.

relatively unexplored. The MedicalUniversity Graz has recentlyinstalled the Genome SequencerFLX System, which has highthroughput as well as improvedreading length and sequencingaccuracy. We are now able to iden-tify the intestinal bacteria via theirDNA and map their consistencyand functionality.’

Currently, patients are beingevaluated and the researchers are

examining the bacteria with thehelp of stool samples. ‘The sam-ples are then sequenced and com-pared with a database. The objec-tive is to find out which groups ofbacteria in the gut have a protec-tive effect against infection. If weachieve this we can then separateand culture just those bacteria anduse them for therapeutic purpos-es. So far some patients with fre-quent, therapy-refractory relapseshad to be treated with enemas

New sequencing tech forthe 1000 Genomes ProjectThree companies that havepioneered development of newsequencing technologies havejoined the 1000 Genomes Project –the international researchconsortium, announced in January,aiming to build the most detailedmap of human genome that willprovide a view of biomedicallyrelevant DNA variations at aresolution unmatched by currentresources.

The new participants: 454 LifeSciences (Roche, Branford, USA);Applied Biosystems (AppleraCorporation, Foster City, USA) andIllumina Inc., of San Diego, USA.

Organisations already committedto major support: Beijing GenomicsInstitute, Shenzhen, China; theWellcome Trust Sanger Institute,Hinxton, Cambridge, UK, and theNational Human Genome ResearchInstitute (NHGRI), part of theNational Institutes of Health.

The NHGRI-supported work isbeing done by the institute’sLarge-Scale Sequencing Network,which includes the Human GenomeSequencing Centre at BaylorCollege of Medicine, Houston; theBroad Institute of MIT andHarvard, Cambridge, Mass., and theWashington University GenomeSequencing Centre at WashingtonUniversity School of Medicine, St.Louis.

Previous studies, such as theInternational HapMap project, haveidentified genetic variants that arepresent at a frequency of 5% orgreater. The catalogue produced bythe 1000 Genomes Project willmap many more details of thehuman genome and how it varies

AWARDS FOR TB STUDYORGANISATIONDr Timo Ulrichs, head of the TB section of the Koch-Metchnikov-Forum, reports on the fight against infectiousdiseases and a strengthening of international tiesIn 2005, former German ChancellorSchröder and Russian President Putinagreed on a strategic partnership to give infectious disease control the highest priority. To fulfil thisagreement, the 5th Peters-burg Dialogue (co-ordinators: Prof.Bergmann, German AcademicExchange Council; Prof. Hahn,Charité and Berlin MedicalAssociation; Prof. Verbitskaya andProf Trojan, St Petersburg StateUniversity) decided to transfer theexecution of this agreement to aGerman/Russian working party ofinfection specialists – named theKoch-Metchnikov-Forum, after bacte-riologist Robert Koch, who describedMycobacterium tuberculosis as theetiologic agent of tuberculosis (TB),and immunologist Ilya Metchnikov,whose work on macrophages formsthe basis of the understanding ofinfection immunology. In October2006, the Koch-Metchnikov-Forumwas officially founded and mandatedon the occasion of the 6th PetersburgDialogue in Dresden, attended byPresident Vladimir Putin andChancellor Angela Merkel.

The Koch-Metchnikov-Forum, anon-governmental organisation(NGO), is politically mandated andwelcomed and there is close and val-ued interaction with German andRussian governments within the

Acinetobacter baumanniigenome sequence determined

‘The normal gut flora is madeup of around 104 bacteria andaround 500 different types of bac-teria in each individual,’ the pro-fessor explained. ‘With the tech-nology available up till now, iden-tification of the different typesand their functions has only beenpossible in a very superficial way,because most types cannot be cul-tured or are only cultured withdifficulty. This is why the role ofthe intestinal flora has so far been

difficile can cause severe infec-tions that can only be treated withspecial antibiotics. In some cases,this can lead to lasting damage tothe gut flora, with subsequentrecurrences of the infection.

One approach to prophylaxis andtherapy would be treatment withthe same intestinal bacteria thatprotect against C. difficile prolifer-ations and release of toxins.

In Austria, a study is underwayto identify the protective bacteriaand consistency of intestinal flora,using high throughput sequencingtechnology. At the Graz MedicalUniversity, Meike Lerner ofEuropean Hospital askedProfessor Christoph Högenauer

MD, in the Clinical Department forGastroenterology and Hepatology,University Clinic for InternalMedicine, why this identificationhas not been made before andwhat his expectations are for thisyear-long pilot study.

that supplied the intestinal florawith the appropriate bacteria forthe elimination of C. difficile. Thisis not particularly comfortable forpatients. The development of newapproaches to therapy and prophy-laxis is becoming more pressing asC. difficile infections are anincreasing problem for hospitals.The reason is the longevity of thespores, which often settle on thesurfaces of bed frames, bedsidetables and toilets and which cannotbe eradicated with normal disinfec-tion agents such as alcohol.

‘For the first time, this new tech-nology offers us the prerequisitesfor mapping the intestinal flora,’Prof. Högenauer pointed out.‘Apart from C. difficile infection,we also expect to be able to put aname against some other “whitespaces” on the map. The study isonly the beginning of the researchthat we will carry out over the nextfew years.’

framework of the PetersburgDialogue.

Koch-Metchnikov-Forumspecific aims● Exchange of humans, ideas and

resources between both countries ● Furthering of scientific, clinical and

social projects in the fight againstinfectious diseases

● Organisation of TB-related sym-posia, congresses, workshops

● Furthering of young scientists andphysicians from both countries

● Furthering continuous medical edu-cation of physicians and healthcareworkers in both countries

● Advice for the governments.Already existing TB projects wereintegrated into the Forum: Since2001, collaborative projects in basicscience (mainly infection immunologyin human TB) are ongoing, with part-ners in Moscow (Central TB ResearchInstitute), St. Petersburg (Institute forPhthisiopulmonology), and Tomsk(Siberian State Medical University).

With basic science TB immunologyprojects being extended by joint pro-jects in microbiological diagnosticsand TB epidemiology, the number ofscientific partners enlarged. Already,studies in TB control have resulted inseveral scientific publications in high-ranked peer-reviewed journals. The TBsection is now accompanied by sec-

between individuals, identifyinggenetic variants that are presentat a frequency of 1% across mostof the genome and down to 0.5%or lower within genes. The 1000Genomes Project’s high-resolutioncatalogue will serve to acceleratemany future research studies ofpeople with specific illnesses.

The full-scale project willinvolve sequencing the genomesof at least 1,000 people, drawnfrom several populations globally,though that number could become1,500 or more. The project will usesamples from donors who havegiven informed consent for theirDNA to be analyzed and placed inpublic databases. Most of thesesamples have already beencollected, and any additionalsamples will come from specificpopulations. The data will containno medical or personal identifyinginformation about the donors.* 454 Life Sciences develops andcommercialises the innovativeGenome Sequence System for ultra-high-throughput DNA sequencing.Specific applications include denovo sequencing and re-sequencingof genomes, metagenomics, RNAanalysis, and targeted sequencing ofDNA regions of interest. ‘Thehallmarks of 454 Sequencing are itssimple, unbiased sample preparationand long, highly accurate sequencereads, including paired reads,’ thefirm reports. This has enabled peer-reviewed studies in diverse researchfields, e.g. cancer and infectiousdiseases and drug discovery etc.* Source: www.roche-applied-science.com/sis/sequencingDetails: http://www.454.com

From left: Vice-Chairman of the Koch-Metschnikow-Forum Heinz Zeichhardt withChairman Helmut Hahn and Timo Ulrichs

tions specialised in HIV/AIDS, hepati-tis, transfusion medicine, e-health andhospital management. In addition, acentral secretariat co-ordinates inter-sectional projects and is the contactaddress for German/Russian partnersand institutions. Besides partners inthe Russian Federation, institutions inMoldova, Uzbekistan and Kazachstanare now Forum members.

The TB projects, and subsequentlythe foundation and organisation ofthe Forum, are funded by theInternational Office of the GermanFederal Ministry of Education andResearch (IB-BMBF) and the GermanAcademic Exchange Council (DAAD).In January 2006, there was also pro-ject-oriented funding by private com-panies (mainly medical and diagnos-tics).

In 2005, the Robert BoschFoundation awarded it prize for civilengagement to the Russian TB controlstudies. During the TB Symposium heldon World Tuberculosis Day 2008, theKoch-Metchnikov-Forum received theinnovation award ‘Selected Landmark2008 in Germany – Land of Ideas’.

An estimated 92 millionChlamydia trachomatis infectionsoccur annually. Often, this diseasepresents no clear symptoms.

Inverness Medical reports thatits Clearview Chlamydia MF testcan provide a diagnosis in as little as 30 minutes, so that, during asingle visit, a patient can also begin treatment.

The test detects the antigen using either female endocervicalswabs or male urine samples, so is suitable for male or femalepatients. ‘The easy-to-use lateral flow test has in-built proceduralcontrols which reliably confirm the test has worked correctly. It usesa unique heating step in the testing process which gives ClearviewChlamydia MF its high sensitivity, meaning clinicians can beconfident in the test results,’ Inverness reports.

30-minute Chlamydia test

Top right: ProfessorVolker SchumpelickRight: Gary J Pruden,CEO of Johnson &Johnson subsidiaryEthicon ProductsLeft: Finesse inmodern meshes


S U R G E R Y

Prevalence of adult obesity hasincreased three-fold since 1990. Theprevalence of childhood obesity hasincreased ten times since 1970. InEurope, almost 50% of adults and over20% of children are overweight. A thirdof these are obese. Conservative esti-mates show that, in Europe, about 100million adults and 10 million childrenare obese. Obesity is accountable for c.one million deaths annually.Costs – Over 6% of direct EU health-care expenditures are attributable toobesity, and obesity related co-morbidi-ties (i.e., type 2 Diabetes Mellitus).Indirect costs, e.g. loss of productivity,obesity related unemployment, etc., aretwice as high as direct healthcareexpenditures. All this underlines theseriousness of obesity as a rapidlyspreading epidemic disease.Prevention Measures – These are

This was it, 15th May, the big day:Johnson & Johnson’s Worldwide MeshTechnology Centre was officially open-ing in Norderstedt near Hamburg,Germany. ‘This is a milestone in ourcompany history,’ said Gary J

Pruden, CEO of the Johnson &Johnson subsidiary Ethicon Products,his presence at the Norderstedt cere-mony signifying the importance of thiscentre to the company.

For Cornelia Groehl, president ofEthicon Deutschland, this inaugura-tion was the successful conclusion oflaborious negotiations. With enormouscommitment she had convinced herUS employers that Germany was theonly logical choice in which to base aninternational mesh technology centre.The company-owned EuropeanSurgical Institute, with excellent con-tacts with top surgeons throughoutEurope, ultimately may have helped totip the scales in favour of Norderstedt.

The team of the new MeshTechnology Centre will focus onresearch, development and productionof meshes for surgery and gynaecolo-gy. The meshes allow minimally inva-sive interventions – a reason forCornelia Groehl to consider the 1.7million building project as ‘an invest-ment in the future’ since the implantmarket records double-digit growth.

The new lightweight meshes arehigh-tech artworks, barely resemblingtheir unwieldy predecessors. The newgeneration of material integrates withweakened tissue, at the same time pro-viding support without harming sur-rounding tissue or causing excessivepain. This technology, which offersimmense benefits to the patients, isused about four million times a yearglobally to repair hernias and othersoft tissue defects as well as in plasticand pelvic floor surgery.

Cornelia Groehl is proud that, withthe Mesh Centre, the company clearlysignals its commitment to the Germansite: ‘It is a recognition for our workand the innovative potential of ourstaff. It’s also a logical decision,because Germany has been the leaderin mesh technology for years – and thisis no coincidence: Physicians are inno-vative, and particularly German physi-cians.’ The fact that Norderstedt alsooffers certain synergies was clearlyalso significant. On site are Europe’smost important production facilitiesfor suture material, needles andabsorbable implants from biomateri-als, including the firm’s EuropeanSurgical Institute (ESI) training centre,where every year over 10,000 physi-cians from all over Europe learn to usethe instruments and MIS techniques.Along with training, they also providefeedback to the trainers, a crucialinput to Johnson & Johnson’s R&D.

It’s no surprise that the surgeonsthemselves gave the decisive drive for the development of the newmeshes. In 1993, Professor Volker

Schumpelick, head of surgery atUniversity Hospital Aachen, and col-leagues discussed the idea of flexible,lightweight and wide-meshed devicesthat could meet the body’s needs. Theywere certain that such a mesh wouldreduce infections and rejections andhelp patients to maintain full mobility.‘People bend and bow and move, theyexercise, they gain weight and womenbear children. Our connective tissues

offer enormous stability combinedwith impressive flexibility – and thematerials that replace and supportweakened tissues should ideally dothe same,’ said Dr Schumpelick.Ethicon Products was then the onlymanufacturer prepared to riskinvestment in the development ofsuch materials. ‘That was coura-geous,’ Prof Schumpelick observed.‘As it went against the trend. I thinkit’s exactly this kind of courage thatis the hallmark of a truly innovativecompany.’ Today, flexible high-techmeshes are an international stan-dard.

20 years of MISBy Professor Ferdinand Köckerling MD, President ofthe DGVC, Head of the Clinic for Surgery, Visceraland Vascular Surgery, at the Centre for MinimalInvasive Surgery, Vivantes Hospital Spandau, BerlinScientific studies confirm that after 20years of minimally invasive surgery(MIS) most of these operations haveadvantages over the equivalent, con-ventional surgical procedures. Forexample, minimally invasive removalof the gall bladder, the method chosenin Germany for about 85% of cases,results in less pain and a shorter hos-pital stay by comparison, even if theconventional removal is performedwith only a very small incision.Endoscopic appendix removal com-pared to the conventional surgicalprocedure also involves less pain,shorter hospital stay and earlier returnto full activity. Due to the lower rate ofcomplications even in complicatedcases, this also means lower treatmentcosts for endoscopic appendixremoval. Despite this, minimally inva-sive appendix removal is currently onlyperformed in around 50% of cases,because an experienced surgical teamis not always available, particularly atnight and during weekends.

Meta-analysis shows that endo-scopic hernia operations carry lowerrisks of wound infection, fewerhaematomas and injuries to nervesand earlier return to normal activityfor the patient. The same rates of suc-cess also apply to bilateral herniaoperations, which occur in up to 30%of cases. Despite these advantagesonly around 35% of hernia operationsare carried out in Germany with MIS

Morbid obesityin Europe

By Martin Fried MD PhD, Professor of Surgery at the Clinical Centrefor Minimally Invasive and Bariatric Surgery, ISCARE-Lighthouse, 1stFaculty of Medicine, Charles University, Prague, Czech Republic

important, e.g. promoting healthylifestyle. Healthy food should be pro-moted and available. So should physi-cal exercise, with more opportunitiescreated for this, e.g. safer roads forcycling/walking.Already obese adults – Ideally, obe-sity management should be concen-trated in specialized centres, thus amulti-disciplinary, scientific medicalapproach to obesity treatment is one ofthe key movements in long-term treat-ment success.Bariatric surgery – From the long-term treatment perspective, the severe-ly obese (Body Mass Index > 35), canbe effectively treated through bariatricsurgery only. Bariatric surgery (eitherlimiting food intake by decreasingstomach volume – e.g. adjustable gas-tric banding, Fig 1, 2, or limiting theabsorption of nutrients and energy bybypassing certain length of smallbowel from digestion of food – such as‘gastric bypass’ or ‘biliopancreaticdiversion’ Fig 3, 4) carries low risks andis significantly beneficial. It not onlydecreases weight, but also substantial-ly improves and/or resolves seriousmetabolic disorders and obesity relatedco-morbidities (such as type 2 DiabetesMellitus, hypertension, and others) inover 80% of obese patients with thesecomorbidities. It also prevents newonset of metabolic diseases.

In 2007, an outstanding break-through occurred. After almost twoyears’ work, Interdisciplinary EuropeanGuidelines for Surgery of Obesity werefinalised and published. For the firsttime in Europe a Bariatric Scientific

Collaborative Group (BSCG) panelwas appointed through the joint effortof major European Scientific Societiesthat are active in obesity manage-ment.

Published Guidelines encourageeffective collaboration in obesity man-agement not only across medical spe-cialties, but also help to standardisemanagement of severely obesepatients in Europe. Recent remarkableprogress is reported in NOTES (NaturalOrifice Transluminal EndoscopicSurgery). NOTES stands on the border-line of endoscopy and surgery.Although still experimental, it mayopen new opportunities in the nearfuture in obesity treatment, indeed ina minimally invasive way – NOTESaccesses the body through the naturalorifices thus providing ‘scarless’ surgi-cal treatment. In the future thisapproach may enable some surgeriesto be performed on out-patients in afew hours.

The Worldwide Mesh Technology Centre

Cornelia Groehl (left) meeting with DanielaZimmermann of European Hospital

Fig. 1 Adjustable gastric banding:restricting stomach volume (foodaccommodation capacity) by creating asmall upper gastric pouch

Fig. 2 Adjustable gastric band device, placedaround the upper stomach, creating an‘hour glass’ shape, with small upper gastricpouch connected with the rest of thestomach by a narrow channel

In the future, the machines at theWorldwide Mesh Technology Centrewill annually create over half a mil-lion surgical meshes, such as Vyproand Ultrapro. Different designs andcombinations of materials will beoffered for a wide range of functions:some implants meant to stay in tissueforever, others to dissolve in a setperiod.

The next generation of meshesenvisaged are bioactive meshes thatoffer more than mere mechanical sup-port for tissue. Cornelia Groehl andDr Schumpelick have no doubts: theapplication potential of mesh technol-ogy in healthcare is far from exhaust-ed – that is why they know theresearch to be conducted at theWorldwide Mesh Technology Centrewill prove immensely important.

Fig. 3 Gastric bypass operation, affectingboth stomach capacity and digestion bydiverting food from one part of the smallbowel, which decreases food digestion,restricting capability to absorb energy

Fig. 4 Biliopancreatic diversion, substantiallydecreases food digestion by bypassing(diverting) food from contact with part ofsmall bowel, thus decreasing food energyabsorption

— again due to the lack of highlytrained surgeons in MIS.

The majority of laparoscopic fundo-plication procedures for reflux are nowcarried out minimally invasively. 10years after minimally invasive fundopli-cation, the quality of life for patients issignificantly better than that achievedwith medicinal therapy. The use of MISfor tumour removal must still beviewed with criticism, although it hasnow been proven that, for patientswith cancer of the large intestine,endoscopic surgery can achieve com-paratively good long term results if theright patients are chosen for the proce-dure.

The key problem for the further MISdevelopment is the long learning curve,i.e. surgeons need to have performed acertain endoscopic operation very fre-quently until they have mastered it inall situations. To meet this requirementthe Surgical Working Group forMinimally Invasive Surgery (CAMIC) ofthe German Society for VisceralSurgery (DGVC) has instigated certifi-cation procedures for surgeons and ref-erence centres. These certificates areonly awarded if a surgeon or a hospitalmeets certain conditions (case num-bers, equipment, training) and passesan audit by experts. As the responsiblescientific associations, the DGVC andthe CAMIC hope for quality assuranceand quality improvements in trainingand therapy for the benefit of patients.

NEW

The Worldwide MeshTechnology Centre


S U R G E R Y‘Our institute for Children’s Emer-gency Surgery and Traumatology,which also includes neurotrauma,trauma, resuscitation, intensive careand others, has a unique character,’Prof Roshal explained. ‘There are noothers of its kind, either in Russia or,actually, the rest of the world. Ourequipment is state-of-the-art; we haveat our disposal CT and MR tomogra-phy with imaging at 3-tesla. We exam-ine traumas using all functional meth-ods. We devote particular attention toproblems concerning severe traumaticpathologies. We also treat acute dis-eases in children, for example peri-tonitis. In 98% of these cases we uselaparoscopy. We have achieved a veryhigh level in treating craniocerebraltrauma, and know a lot about crushsyndrome, having accumulated a pro-found experience in the treatment ofthis condition.’

The institute could and shouldbecome a centre of education andtraining for emergency medical assis-tance for children, not only in Russia,but also for personnel in countriesworldwide, he suggested. ‘We cancarry out seminars and conferences on all these subjects. I have alreadystarted on this endeavour. Within theframework of the World Associationfor Disaster and Emergency Medicine(WADEM) congress, held every twoyears, we hold specialised sessions toconsider and discuss related prob-lems. Called Children in Disasters

and Wars, these sessions have beenheld for many years on our initiative.We began with one session, now thereare two. Nevertheless, to my mind theinitiatives taken are far from sufficientto solve the problems existing in thisspecialised field. Focused educationand training is needed, and we areready to provide such training; we areavailable and have top-rank experts atthe Institute. The bulk (99%) of theinternational medical team who assistat disaster sites are our specialists.Because this is part of our Institute’sactivity, we have several emergencyteams. Practically every day we dealwith emergency cases in Moscow; it isour routine work and we have enoughstaff on the spot to carry it out. In themeantime our medical teams set off togive help at emergency sites any-where. Their complement varies; per-haps 10 or maybe 14 people. We alsoreplace people if necessary. For exam-ple one group returns and anotherdeparts for the emergency site.’

The Institute first provided assis-tance following an earthquake inArmenia in 1988. Since then it hasbeen a notable presence at disasterand earthquake sites in Georgia,Russia, Algeria, Egypt, Turkey, Iran,India, Pakistan, Japan, three times inAfghanistan, and for a month recentlywas present in Indonesia. ‘We haveactually walked the whole equatorfrom west to east,’ Prof. Roshalremarked. ‘At first, it was only myhypothesis. Then I came to a firm opin-ion that highly skilled paediatric spe-cialists could help children more effi-ciently compared with physicians foradults. Children have particularitiesthat need special attention. In treatingthem, our experience has totallydemonstrated that the death toll aswell as disablements is approximatelytwice lower when our paediatric teamis doing the relief work.’

For many years, Prof Roshal hasbeen on the Board of the WADEM. ‘Itis from this position that I engage inproviding assistance to children when-ever emergencies arise. And it hasbecome clear to me that we need aunited, efficient structure that canorganise emergency aid for childrenthroughout the world. We do not havethis. I would prefer this structure to becreated under the aegis of the WorldHealth Organisation. The WHO has itsspecific features; all participatingcountries pay for the implementationof its concrete programmes. To my

For the world’s children–from Russia with love

For 20 years a unique paediatrics team from Russia has provided a significantly welcome presence atnatural and man-made disasters worldwide. During our interview with Professor Leonid Roshal MD,Executive Director and Chief of the Scientific and Research Institute for Children’s Emergency Surgery andTraumatology, in Moscow, he recollected areas in which the team’s assistance provided medical aid andpointed out ways in which countries worldwide could improve disaster care for the children of today

and those of the future. Journalists have dubbed him ‘The Children’s Doctor of the World’

regret, a programme to renderservices to children in emergencysituations is not provided for.Nonetheless, I hope that possibili-ties can be found in this direction.I’m not even contemplating thisproblem from the point of view offinancing the scheme. The mainthing is the overall organisationalwork – throughout the world.

‘Teams to provide medical serviceto children should be formed on thenational basis, for which the

arrived by air in Islamabad, settleddown in the major children’s hospi-tal there and began to collect thechildren with the gravest problems,such as crush syndrome, crush kid-ney, and craniocerebral trauma, totend these small patients in hospital.’

Along with his belief that spe-cialised emergency medical teamsfor children should be organised at anational level, he also believes it nec-essary to form such emergencyteams on the basis of geographical

needed at the scene needs to beclear in order to deploy the staffadequately – perhaps five or 10 trau-matologists should be sent, but noneurosurgeons or reanimation spe-cialists are needed. It is of majorimportance that information comesvery quickly and is precise. At pre-sent, there is no effective informa-tion on the necessary medical aidfor children at emergency sites; thisis a weak point.’

There is another highly important

We also expect among hospitalisedpatients a number of children sufferingvery severe conditions, such as crushsyndrome, craniocerebral trauma aswell as extensive wounds. We havephysicians at our disposal who spe-cialise in treating extensive woundscomplicated by fractures. If we can goto the site, how it should be handledwill be clear to us. However, we havenot received any answer from theChinese authorities. Meanwhile timeflows away; in ten days we shall behardly any use: amputations willalready have been performed, and it isprobable that a number of childrencould already have died.

‘Actually, reviewing in my memory ofthe emergency cases in which we pro-vided medical assistance, I cannot rec-ollect a single occasion when a countryaccepted our offer to give help at once.National peculiarities connected withsovereignty come to the fore. At first,we are always confronted by refusals.This has been the case everywhere –Japan, India, Indonesia. They said theypreferred to manage by themselves.But once we were at the site and work-ing it usually took only an hour or twoto clarify who was who, if I may put itthat way; our role changed rapidly – webecame leaders of fashion. Our workdone, we’ve been rewarded with grati-tude from each government.’

Children have physiological as wellas psychological peculiarities thatmust be considered when treatingthem, he stressed. ‘Proceeding fromthis assumption, the necessity of build-ing up a structure for an emergencymedical service exclusively for chil-dren really does exist.’

Asked how long he has worked forchildren we discovered this is a land-mark year for Prof Roshal. After gradu-ating in paediatrics 50 years ago heworked for some time as a paediatri-cian before becoming a paediatric sur-geon. ‘I’ve mainly engaged in emer-gency paediatric surgery, always basedin Moscow, but I have worked through-out the world.’

Fifty years of dedication to savingchildren. We congratulated him andexpressed hope for his good health tocontinue.

‘Thank you for your good wishes,’replied Prof Roshal. ‘As far as myjubilee is concerned, I’d say 75 is noage at all.’

Meike Lerner from European Hospital met ProfRoshal, Executive Director and Chief of theScientific and Research Institute for Children’sEmergency Surgery and Traumatology, in Moscow

regions, taking advantage of theirresources. ‘In the case of anextremely large number of injuredin a certain country and its owninsufficient resources, medical aidought to be covered at a regionallevel. Besides this, a special interna-tional structure should exist; teamsof physicians should be able toarrive by air in the disaster site –and here, the coordination of effortsamong different organisationsinvolved is the crucial point.Additionally, in a medical emer-gency it is essential to evaluate thenumber of injured and the scale ofdevastation. The kind of specialists

Russian experience could be put togood use. A team can include neuro-surgeons, traumatologists, special-ists in burns, plastic surgeons, inten-sive care and reanimation and pae-diatric surgeons as well as paediatri-cians, but it should be staffedaccording to the nature and scale ofa disaster. Such are the principlesunder which our mobile teamswork. That practical experience hasproved the expediency of formingemergency teams of this kind at anational level.’ When a disasteroccurs, particularly on a large-scale,he pointed out, ‘… we are confront-ed by a deficiency in highly qualifiedpersonnel.’

The Russian team does notengage directly at an emergencysite, he added. ‘We don’t stand nearhouses waiting for our patient to berescued from the debris. This impor-tant and hard task is accomplishedby pre-hospital relief teams, bymobile clinics, not to forgetMedicines sans Frontières, the RedCross, and so on. We concentrateour efforts at the hospital stage ofchildren’s treatment. For example,after the Pakistan earthquake, we

point: ‘There are always many vol-unteers who wish to help, but noteveryone who comes to a site witha kind heart is qualified enough tocope with the tasks. It’s the skilledpersonnel who are needed, withlicenses and a good training. Only aprofessional workforce can reallyhelp.’ He emphasised two principalfactors as to children necessary tomanage disaster medical care tochildren: timely intervention ofhigh-skilled personnel.

Four days before our interview,the team had applied to China’sgovernment (via the ChineseEmbassy in Russia) to enter thecountry’s earthquake region andjoin the medical teams there. ‘TheRussian Embassy in China has alsoapplied to China’s Ministry ofForeign Affairs,’ Prof Roshal said.‘From our experience and calcula-tions we can expect 80,000 injuredfrom the death toll of 20,000.Hence, based on the adult/childrenratio, we can calculate the numberof injured children; we can alsoestimate the rate of injuredchildren who definitely need hospi-tal treatment – it should be 20%.

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W O U N D M A N A G E M E N T

Hair follicles, long disregarded byresearchers, except in the cosmeticindustry, may turn out to be ‘the foun-tain of youth’, according to AndreasEmmendörffer, CEO of Germanbiotech firm Euroderm. The use of afew hairs can help to heal chronicwounds, Euroderm reports.

Just a few years ago scientists dis-covered a surprising detail in the hairfollicle: It contains not one but threekinds of adult stem cells. Even moreinteresting, these are not only part ofhair regeneration but also play animportant role in skin repair.

Usually, hair stem cells are involvedin hair growth and pigmentation. Thelifetime of a hair lasts two to six yearsand goes through three stages, whichrecur continuously. For most of the life-cycle the hair is in the active stage, fol-lowed by a transitional stage that lastsonly three weeks, then a resting phaseof four further months after which thehair is shed.Then a new hair is built up.

However, the story does not endthere. In addition to the melanocytestem cells, which are responsible for

RUSSIA’S SPECIALISTWOUND SURGEONStreet fights, earthquakes or simply everyday life frequently produce infectedwounds that only specialist surgeons can treat. EH Correspondent Olga Ostrovskayainterviewed Valerij Mitish, whose expertise borders on the unique

A meeting with Dr Valerij Mitishwas difficult to arrange – every dayhe’s at a different Moscow hospital.Yesterday he carried out acomplicated wound procedure in achildren’s hospital; today he’s at theMilitary Institute, tomorrow it willbe the Endocrinology Centre. Healso heads the department ofwound infection and woundsurgery at the Moscow Researchand Clinical Institute of EmergencyChildren’s Surgery and Trauma. Inaddition, Dr Mitish heads a team ofRussian surgeons that helps inother countries following disasters,and is professor of disastermedicine at the Russian Universityof National Friendship. Betweenprocedures at the EndocrinologyCentre, we finally met.

Asked why he must changelocations so often and whether thehealthcare system is short ofsurgeons for infection he explainedthat specialists in infection surgeryare a rarity. Why? Mainly due to thecomplexity of this kind of surgery:several phases (2, 3, 4 etc.) arerequired. ‘First we excise thewound; next plastic surgery mustbe implemented.’

Is he also a plastic surgeon?‘Sure. To gain the best results inwound treatment, we believe thesame doctor should stay with thesame patient. 50% of our surgicalwork is plastic surgery. Mycolleagues totally manage theplastic skills – from simple ones totissue micro transplantation. Wemust not only reconstruct the

organ, but also its function andaesthetics.’

This is great! But why are do fewsurgeons want to become woundinfection specialists? ‘Traditionally,in the Russian healthcare system,doctors regard this kind of surgeryas a punishment – for poor studies,for bad work. Our specialty usuallyhad the oldest equipment andpatients are treated for severalmonths – so it’s impossible to bepaid big money here… And oftenyou have to work with blastedtissue, stuffed with pus.’

So why is he a wounds surgeon?‘It’s a very interesting specialty! Ithink I’m lucky to understand this.This was the USSR when I began tooperate. I worked at the VishnevskijInstitute of Surgery, which wasoriented towards military anddisaster wounds. It was there, inthe beginning of 70s, that the firstwounds and wound infectiondepartment was set up. A strategyfor active surgery was created – thesurgeons didn’t wait for “ripening”of the wound to treat an abscess;they operated without wasting time.

We also had a special air medicalservice and I flew to the furthestareas of Russia to treat the mostcomplicated cases. As a result, I’vegained great experience.’ Dr Mitishspeaks with sadness. ‘We had anexcellent system for treatingdifficult cases in every area of thecountry. We could get these patientsto Moscow for follow-up treatment.We had 20-30-40 most interestingcases at the same time. It’s reallysad that this system has now beendestroyed.’

What can be done in thecircumstances? ‘We try to share ourexperience with our colleges indifferent Russian locations, atcongresses and in universities. In2000, I lectured French surgeons inParis about the treatment ofosteomyelitis after trauma. A lot ofsurgeons come to my operations.Now we use the most advancedmedical technologies to treatwounds. When we go to countriesafter earthquakes (in Pakistan, forexample) our colleges from othercountries can use our experience.’

This interests them? ‘Sometimesthey say they can’t do such complexsurgery back home, they say “youcan do everything without us”. Ithink we have such rich experiencebecause we have a lot of difficultcases after various situations inRussia: regional wars, explosions inour cities, knife and gun woundsdelivered on the streets – a lot ofreally small disasters. And we canuse this experience in treating fightwounds to treat common ones.’

Wound managementin practice

A question of authoritybetween doctor and nurse

Marie-Luise Müller isPresident of DeutscherPflegerat e.V. (GermanCare e.V) Council, and

Chair of its Congress, which washeld alongside the CapitalCongress on Medicine and Health2008 in Berlin this June. Duringour interview, we asked herwhether there is too little Germanmedical and political recognitionof nursing as a health professionin its own right. In agreement,Marie-Luise Müller pointed outthat this is mainly to do with thesocial insurance system and thebasic understanding among themedical fraternity. ‘The Social

all Anglo-Saxon countries this aca-demic qualification is alreadyavailable. In the USA there arealready 106,000 nurse practition-ers, working under various condi-tions of employment, and someare self-employed. For chronicwounds, they take over the com-plete anamnesis and investiga-tion. They are informed about cur-rent wound care studies, carry outtherapy or delegate it to a nurse,something that the doctor used todo. They also use IT. They docu-ment wounds with photographsand send these to specialists, con-sult with them and then return tothe patients. I believe nurse practi-

Welfare Code volume V does notrecognise care services, whichmeans care is always listed as asub-item under medical services.It’s a long-standing problem fromwhich the structures of our medicalfraternity have evolved and theyare completely set. This goes handin hand with the general Germanmentality, which is always initiallyvery skeptical about change of anykind. German doctors fear a de-professionalisation of their rank, sothey cling to their personal positionof power.’

Whilst the doctor’s role andimage has been established forover 150 years, the nursing profes-sion is only now questioning it, sheadded, and this very much involvesthe transfer of responsibilities, par-ticularly for wound care. A sur-geons guideline stipulates thatthey must apply the first wounddressing after surgery, as well asthe last i.e. before hospital dis-charge. ‘However, this only refers towounds caused by surgeons, wherethey know the exact anastomosisor the surgical thread used, andwhere they can assess whether anyendogenous infection is present. Inthis case, it is understandable thatthe doctor wants to take personalresponsibility. We do not disputethis. Our main concern is in thebroad spectrum of chronic wounds,such as diabetic foot etc. These areall widespread diseases where weneed to observe the patient as awhole. Specialist doctors are onlyconcerned with their field of spe-cialisation. Moreover, wound carerequires certain capacities andresources. Sometimes there are 10nurses to every doctor. That’s why Ibelieve it is right that in certainareas there should not only be adivision of labour but also an actu-al transfer of tasks and responsibil-ity.’

Asked about the opportunitiesfor nurses that result from the newLaw on Further Developments inCare, under which they can practicecertain aspects of medicine undercertain conditions, she believes thishas paved the way for academicconcepts. ‘I can foresee there willbe nurse practitioners with an MBAqualification in Germany no laterthan 2012. In 2009 the first Germanuniversities will start running therespective degree courses in nurs-ing care. In the Netherlands and in

tioners are the drivers here,because they work right where itis happening, with broad access topatients. They can help them, forinstance, to change their diet, ordiscuss questions about hygiene orsexuality. Usually there is not thesame scope for this when patientstalk to doctors. A nurse practition-er would have far more training inleading such conversations. So, Ibelieve we should approachpatients not only clinically but inconsideration of their generalenvironment, circumstances andhealth.’

How would wound care special-ists be integrated into the dailylife in hospital? ‘Many hospitalsalready use good wound experts.Large hospitals in particular tendto have specialist wound caredepartments, where in- and out-patients can be treated. There isalready good dialogue betweenspecialists and wound experts inthose departments. Out-patientcare is a little more involved; forthis nurses have taken many train-ing courses so are often betterinformed than doctors. The prob-lem in hospitals revolves aroundthe transfer of responsibility. Thetransfer management writes acomprehensive wound care reportfor the patient’s general practi-tioner (GP). This is often ignoredby many GPs because they lackknowledge. Obviously it makessense to do something about that.The public is increasingly awarethat we live in an ageing society aswell as a society which calls formore autonomy and personalresponsibility when it comes tohealth. This is why people are enti-tled to have their wound dressingschanged by somebody who ishighly specialised and qualified todo it.’

Marie-LuiseMüller

Hair helps chronicwound healing BIOTECH FIRM GENERATES SKIN FROMMOTHER CELLS IN PATIENTS’ HAIR FOLLICLES

hair colour, researchers also found themesenchymal and epithelial types ofthese ‘mother cells’. ‘It was very wellknown, that mesenchymal turn into dif-ferent kinds of tissues, for example, theinner organs, whereas epithelial onesare able to regenerate skin,’ AndreasEmmendörffer explained. Scientist dis-covered that both kinds of stem cellsare activated by damaged skin and con-nective tissue. While the skin stem cellsmigrate to the skin surface, the mes-enchymal are involved in healing deep-er wounds. These findings triggered theidea of growing skin from hair.

Euroderm adopted a method intro-duced by Professor Thomas Hunzikerand team at the DermatologicalUniversity Hospital in Bern,Switzerland, and developed it into to atherapy for patients. The proceduresounds simple: The patient provides afew hairs, depending on the size of thewound. The hair is immersed in a solu-tion that contains a cocktail of growthfactors, including epithelial growth fac-tor. These stimulate the proliferation ofthe skin stem cells. ‘First they grow in

one layer, but once the number of cellsexceeds a critical amount, we stimulatethem to build up further layers – or sim-ple to make the epidermis thicker,’Andreas Emmendörffer explained. Aftertwo to three weeks the new skin isready to be grafted onto the wound.‘We stabilise the thin plaster on a plas-tic film, which makes it easier for doc-tors to transfer it to a wound,’ he point-ed out. Surprisingly it is not necessary tocover the entire wound with the newgrown skin. The patches tend to expandand connect with one another.

The new treatment has proved suc-cessful, he said: ‘In a clinical trial, 60-80% of the patients had closed woundsor benefited at least from a significantreduction in the size in a few weeks.’Equally important, he added, to date nocritical side effects have appeared.

Dr Valerij Mitish

Pressure

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Movement and frequency of pressure ulcers

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Pressure ulcersHeidi Heinhold, of the German League for Decubitus Ulcers,sums up physiological basics and practical care issues

Pressure ulcerstages revision

USA – Following five years of work,which began with the identification ofdeep tissue injury in 2001, the NationalPressure Ulcer Advisory Panel (NPUAP),in Washington DC, has redefined thedefinition of a pressure ulcer and thestages of pressure ulcers, including theoriginal four stages, and adding twostages on deep tissue injury andunstageable pressure ulcers.

The staging system was defined byShea in 1975 and provides a name tothe amount of anatomical tissue loss.The original definitions were confusingto many clinicians and lead to inaccu-rate staging of ulcers associated or dueto perineal dermatitis and those due todeep tissue injury.

The proposed definitions wererefined by the NPUAP with input froman online evaluation of their face valid-ity, accuracy clarity, succinctness, utility,and discrimination. This process wascompleted online and provided input tothe Panel for continued work. The pro-posed final definitions were reviewedby a consensus conference and theircomments were used to create the finaldefinitions.* Source/details: [email protected]

Physiology is the science concernedwith the processes and functions of anorganism. Profound knowledge ofphysiology allows us to recognisestates that deviate from the norm anddecide whether these anomaliesshould be classified as diseases or dis-orders and thus require care. The initialinstrument to assess a patient is thecare history. The second mandatorystep is the definition of realistic careobjectives, the planning and imple-mentation of care measures and theassessment of the results in terms ofquality control and nursing science.

lem. Mechanical obstacles, such asoccluded venules or insufficient oroverburdened lymph precollectors,cause fluid build-up between cells. Thisfluid contains, for example, proteins,fats, anaerobe bacteria, cell toxins andother substances that need to beremoved through the lymphatic systemas quickly as possible, but which can-not be removed since an interstitialoedema blocks the way.

Interstitial oedema are tissue alter-ations that the most recent NPUAPclassifications describe as induration,oedema, painful, soft, exuding, warmerbut also cooler than the adjacent tis-sue. These symptoms indicate a deeptissue disorder that, if untreated, candevelop into pressure ulcers. Ideally, adifferential diagnosis with the help ofimaging methods provides answers tosuch phenomena. From a physiologicalpoint of view, these tissue alterationsrequire the patient to be moved, toactivate the venous flow and enablethe lymphatic pre-collectors to removethe interstitial liquid. Frequent reposi-tioning is necessary for the local liquidaccumulations to dissolve sponta-neously, which is still possible in thisearly stage.

Rubefacient ointments, heating orcooling and massages must be avoid-ed, because such measures increasethe arterial inflow to the regions atrisk. Consequently even more liquid isreleased into the interstitial spaces,which means the oedema grows andaggravates the situation. Thus the riskof infectious decubitus stage I as a dis-ease stage would be heightened ratherthan reduced.

Nurses should be trained to recog-nise palpable superficial tissue changesand in turn train family carers, sincethis effectively and significantlyincreases early detection and preven-tion of pressure ulcers.

What makes bedsores tick?By Friedhelm J Baisch PhD (med. Eng.) of the Institute for Aerospace Medicine*, Cologne, Germany

Fig. 2 The red curve shows themovement frequency of the variousareas and parts of the body. Thehead and upper body move morefrequently (or are mobilised, e.g.during food intake). Moremovement occurs even in the heelregion than in the coccyx.Movement and position are the keyparameters for bedsore prophylaxis.

Pressure

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Care history is risk assessmentThe assessment of a pressure ulcer risksencompasses (beyond a patient’s ageand sex) the following:● biological age and state of hydration

of local cells, particularly in skin andsubcutaneous tissue

● state of deep tissue● state and functioning of blood vessels● state and functioning of the

lymphatic system.A patient can rarely provide informationon these aspects because, while he prob-ably remembers recent injuries or throm-boses, embolisms or known vascular orlymphatic diseases, he is probably notaware of the effects of such injuries orconditions on tissue. The skin turgor(elasticity) provides a first indication ofhydration. Pressure on the tissue allowsa general assessment of the micro-circu-lation: if the tissue blanches and the ves-sels do not refill after a few heartbeats, acirculation disorder is present which canbe further differentiated:● bluish-grey colour indicates a venous

disorder of the micro-circulation ● if the site where the pressure was

applied remains white for some timeand is even cooler than the adjacenttissue an arterial disorder of themicro-circulation has to be suspected.

In the first case the flow of blood andinterstitial fluid is disturbed; in the sec-ond, the tissue is inadequately suppliedwith blood. Moreover, there is an as yetunverifiable lymphatic drainage prob-

Key parameters for prophylactic mobilisation in cases of bedsores:Fig. 1 Pressure level (continuous white line) in regions at risk for bedsores (occiput, shoulder blades,coccyx, ischium and heels). It has been shown that bedsores always develop around the coccyx andischium, even though the pressure exerted on these regions is not particularly high. However this pressuredoes exceed the critical threshold (gray dot-dash line). On other hand, it is curious that bedsores do notalways develop on the heels, where the highest pressure values occur. Moreover, by rights bedsores shouldbe as prevalent on the occiput as in the coccyx region, since the surface pressure there is nearly the sameas in the gluteal region. The critical threshold for surface pressure in this region is slightly under 20 mmHG,which is based on the pressure collapse values for older, cachectic patients in a reduced hydration state.This level is age dependent, and varies inter-individually and according to body region.

According to a study by theGerman Aerospace Centre,bedsores are mainlyinduced by a combination

of gravity and immobility. Gravityexerts skin pressure and tissueshearing stress, which in turn pro-voke pathological changes if patientmobility is not encouraged.

Non-invasive, in vivo detectionof intra-tissue pressure andtension

Previous calculations regarding thepathological effects of pressure onbiological tissue were realised inanimal models. Such investigationsgave rise to findings such as theKosiak postulates, which wereextrapolated from investigations oftissue pathologies. These postulatesallowed investigators, for the firsttime, to measure stress on humansoft tissue using a non-invasive self-constructed pressure stamp and, atthe same time, to observe and docu-

ment the physiological processes inthe terminal vessels of the skin andmusculature non-invasively.

In this process, erythrocytemovement in the capillary bed wasmeasured in the force direction ofthe pressure stamp using a Dopplerlaser, while at the same time theerythrocytes were counted and theoxygen load was measured using awhite light spectrometer.

In the gluteal region, the pressurestamp was pointed directly at theischium. The force was thenincreased in defined incrementsuntil erythrocyte movement ceasedin the tissue under the stamp. Up to50 Newtons were exerted on theskin, with peak pressure ranging ashigh as 100 mmHG. The deforma-tion was then stepped down usingthe same increments.

FindingsThe force exerted during the vari-ous pressure stages was not con-

stant. The force was higher at thebeginning of each deformation andthen declined to a lower level. Thetissue reacted plastically.

The number, oxygen saturationand movement of the erythrocytesdecreased as force and deformationlessened. However, substantialnumbers of erythrocytes weretrapped in the capillary bed whenthey stopped moving. The oxygensaturation of these erythrocyteswas initially high, but decreased aslong as the pressure remained con-stant.

Conclusions Kosiak’s hyperbola model should beexpanded, as this would allow theeffects of altered hydration status tobe brought into play.

Although tissues tolerate pres-sure peaks for brief periods,pathologies are provoked by ery-throcyte oxygen depletion, i.e. in

continued on page 20



cases where tissue deformationaccompanied by flow stasis remainsunchanged for an unduly long period.

The amount of oxygen consumedby maintenance metabolism indi-cates that tissue deformation is toler-ated by nerve tissue for only a fewminutes, by skin and inactive muscu-lature by approximately 60 minutes,and by cartilage for several hours.This process of deformation pro-vokes erythrocyte stasis owing to theweight exerted on the surroundingcapillary bed.

Kosiak showed that a small


Investigating new wound healing approaches

Optimising chronic wound careProcess optimisation is a major issue in any healthcare facility, say Ellen Schaperdoth,

Claudia Roland, Rudolf Pape, René A. Bostelaar. Some organisations have alreadycome a long way, others are just about to attempt the first steps

Process optimisation concernsall primary and secondaryprocesses in a hospital. Casemanagement is a tool thatsupports the implementation ofcomprehensive optimisationefforts. The Cologne Case

Management Model is designedas a process of interdisciplinarycooperation in patient care. Itencompasses assessment,planning, documentation,coordination, organisation andevaluation of healthcareservices. During assessment andduring the extended processmonitoring by the case managerthe wound manager identifiespatient needs and initiatesagreed solution-oriented actionssuch as wound management.

At University Hospital Colognecentral wound management hasbeen implemented in the contextof introducing case management.

There are several treatmentstrategies for the care of chronicwounds. New research highlightsthe complex processes involvedin wound healing. Industryseems to exploit this trend topresent ever more complexproducts. However, for the userit is increasingly difficult to gainan overview over the broadrange of available wound careproducts. Moreover, cliniciansadhere to different theories andpractices regarding wound care,making this issue a bone ofcontention that leads tounnecessary distress. Ineveryday hospital life manypatients are subjected tochanging treatment methods,which means a lack of continuityof care. Different materials withwidely differing timerequirements, and above alluncontrolled costs, are appliedwith uneven success.

BEST therapy for chronic woundsThe recently launched KFH Novofrom Kingfisher Healthcare (KFH) isa non-invasive medical device thatutilises Bio-Electric StimulationTherapy (BEST) to deliver extreme-ly low levels of current to chronicwounds. This does not interferewith standard conventional thera-py; the electrodes are placed someway from the wounds, beyond thenormal treatment areas.

Kingfisher reports that thetherapy has been shown to healdifferent types of chronic woundssuch as venous ulcers, pressuresores and diabetic ulcers, even ifopen for longer than a year.

DEVELOPMENTS INDRESSINGS AND BEDDING

amount of pressure can result in acritical weight threshold beingcrossed, which in turn provokes tis-sue subsidence if the deformationremains unchanged.

Enlargement of the contact sur-face via softness does not solve theproblem, since softness is habitforming and undermines thepatient’s already diminished desireto move autonomously. Hence soft-ness indisputably promotes bothimmobility and a negative bodyimage. In this respect, it is essentialthat immobile patients be mobilisedseveral times daily by a nurse, phys-

iotherapist and/or the family care-giver. Only in this way can bedsoresbe avoided.

The current annual social cost ofbedsore treatment is about 0.8 bil-lion euros (2006 figures), which islikely to reach two 2 billion euros incoming years due to increasinglyaged populations. * Institut für Luft- und

Raumfahrtmedizin, Deutsches

Zentrum für Luft- und Raumfahrt e.v.

Article based on a lecture delivered

before the German Bedsore

Association (Deutsche Dekubitus

Liga) in Berlin in May 2007.

Wound management goals

● Standardisation of wound care(following established guidelines),

● Process optimisation ● Economic use of products.Wound managers’ tasks are to

● advise and care for patients withchronic wounds

● develop guidelines that ensurestandardised and consistentwound treatment

● reduce and standardise woundcare products by removingunsuitable materials andmedication

● train medical and nursing staff ● ensure the continuity of care by

appropriate data collection andharmonisation of IT-based wounddocumentation.

Milestones achieved:

The hospital board adoptedguidelines for the treatment ofdecubitus, diabetic foot syndromeand ulcus cruris. The stock ofwound care products was updatedand restructured in order to makeall procedure-relevant materialsimmediately available to the staff.Pharmaceuticals of questionableeffectiveness were removed.Consignment stock was establishedfor vacuum therapy material.

The first training courses forwound managers began inNovember 2004 and were completedin February 2005. Additionalcourses took place from September2006 to March 2007 and from April2008 to July 2008. The coursecontents were supported by bedsideteaching on wards. All newmembers of staff receive trainingfor new products.

To improve and harmonisedocumentation, the internal ITsystem was modified and iscurrently being tested in someclinics.

The first wound manual waspublished in July 2006.

Responsibilities

Upon admission of a patient withchronic wounds, e.g. decubitus,diabetic foot syndrome, ulcuscruris or secondary healingwounds, wound managementshould be paged during assessmentby the case manager(s). Duringjoint wound assessment (casephysician, the nurses and woundmanager) photo documentation iscreated and the therapy conceptdesigned. The agreed therapy isdocumented on the wounddocumentation form or thetemperature chart.

Monitoring, changing ofdressings and the concomitantdocumentation on the wounddocumentation form are theresponsibility of the nurses and/ormedical staff. Support and adviceduring treatment are theresponsibility of the trained woundmanager.

The treatment plan is reviewedin regular and previously agreedintervals by the physician in chargeand the wound management team.The plan is modified as needed.The case manager is informed.

To facilitate scheduling, thedifferent departments are offered afixed ‘visit day’. Definedprocedures facilitate treatment ofchronic wounds and ensurecontinuity of care.

Further guidelines, for exampleregarding decubitus prevention, arecurrently being developed.

Roughly every six months awound colloquium is scheduledwhere internal and external staffmembers present their results andundergo additional training.

Process optimisation ensuresthat problems are identified earlyand that appropriate solutions canbe immediately initiated.Further details: rudolf.pape@uk-

koeln.de

Professor Raf Meesen, of LimburgUniversity College, Belgium, said:‘The initial results with KFH Novoappear to be very promising. Somewounds that we could not getclosed with standard treatmentshealed completely when this wasapplied.’

BEST works by enhancing thephysiological processes of woundhealing; documented effectsinclude:● Attracting the right cells to the

wound area, e.g. keratinocytes(cells which make up 90% of theouter layer of skin called theepidermis)

R E S E A R C H

Dressing changes need not be painful

Thinsulate Thermal Insulation

Little research has been carried outinto new therapies for wound healing.As chronic wounds tend to be classedas side effects of other diseases, e.g.diabetes, they are often treated astrivial. However, the body’s capacity toheal itself often does not set in forweeks.

Still the most important initialchoice of treatment, wound dressingsnot only protect an open wound fromfurther infection, but also the activesubstances they contain encouragehealing, which can be effective partic-ularly at the early stage. However,conventional dressings are manufac-tured from collagen — made fromhuman or animal connective tissue –so cannot guarantee germfreehygiene. Lack of oxygen due to woundcovering can cause further problems.The quality of materials is thereforedecisive for successful therapy.

At the Bayer subsidiary BIG (BayerInnovation GmbH), project teamsworking on various innovative woundhealing therapies and treatmentstrategies are researching high-qualitysubstances and modern procedures,Bayer reports. They are using the char-acteristics of the well-known silica gelbased on scientific findings at theFraunhofer Institute for SilicateResearch in Würzburg, Germany. ‘Notonly does it ensure germfree cleanli-ness during treatment, but the fibresof the silica gel also have the positiveability to make skin cells stick to themfaster and better so that newly devel-oping fibrous tissue has better sup-port,’ Bayer explains. ‘The natural

structure of the wound closure facili-tates an optimum supply of nutrientsfor the newly forming connective tis-sue. As the wound dressing isprocessed by the body at a slower pacethan other materials this allows foroptimum cell proliferation.’

‘When the protective bond decom-poses too quickly, or is not structuredenough, which leads to a large accu-mulation of skin cells. This in turn leadsto an undersupply of these cells withnutrients. In the end the internal cellsdie and the newly formed tissue col-lapses into itself,’ adds Iwer Baecker,Head of the Project for BioresorbableSilica Gel.

In the future, the BIG investigationinto completely new methods may leadto a move away from conventionalwound dressings. One issue is of par-ticular interest. ‘At the moment onlyflat wound dressings are available,’ DrBurkhard Fugmann points out. ‘This iswhy we have tried to find a materialthat will adapt to the actual shape of awound in a better way.’

Further optimisation of active sub-stances is another important area ofresearch. Bayer’s approaches centrearound the addition of growth factorsthat are lacking within the chronicwound, and inhibitors that prevent thebreak down of growth factors throughprotein-decomposing enzymes. DrFugmann’s long-term goal is the devel-opment of a ‘…building set for chron-ic wound healing’, which bringstogether the optimum combination ofdifferent treatment methods.Source: Bayer

Chronic wound patients can experi-ence acute pain during dressingchanges.Additionally, inappropriate orsometimes aggressive adhesives ondressings can cause trauma to thehealing wound bed and surroundingskin.

Clinically significant patient bene-fits of specific advanced wound dress-ings have been highlighted in a largemulti-national survey of patients (pub:Wounds UK journal). The Pain onRemoval Cases (PORC) surveyinvolved over 3,000 patients with var-ious wounds, from 20 countries. Over90% of them said they preferreddressings with Safetac* soft siliconeadhesive (Mepilex was used in thestudy) because they suffered less painduring dressing changes than when

advanced dressings with traditionaladhesives (e.g. polyurethane, acrylic orhydrocolloid-based) were used.

‘The PORC survey illustrates the ben-efits of using dressings with Safetactechnology in terms of reducing pain,’commented Dr. Richard White,Professor of Tissue Viability at theUniversity of Worcester in UK.‘Hopefully the results of this prelimi-nary survey will contribute to increasedawareness among healthcare providersof the importance of recognising andmanaging patients’ pain during wounddressing related procedures.’* Safetac dressings are produced by theWound Care division of Mölnlycke HealthCare, manufacturer of single-use surgicaland wound care products and services forhealthcare.

Because the dirt and liquid repellentfibres used in Thinsulate InsulationType Z are substantially thinner thanconventional fibres, less material isneeded to store the same amount ofheat, its manufacturer 3M reports.‘The bedding is therefore lighter inweight and much more comfortablefor patients suffering open ulcers orpost-surgical wounds, for example,and yet it still provides soft, cosy pro-tection against the cold. At the sametime, the hydrophobic fibres ideallycompensate temperature changes andtheir breathability allows unpleasantperspiration moisture to escape.’

Laundering – The material’s compres-sion resistance and quick recoveryensures that the bedding does notbecome lumpy or fall apart, despitemany washing cycles. In addition, itslight weight and low volume mean morecan be laundered per load and drying isquicker, all resulting in cost saving.

Available in three different lofts (120g,150g and 250g) for different thermaland comfort requirements, the materialis also hypoallergenic and meets theecological requirements of the Oeko-TexStandard 100 Classes 1 to 4.

Details: www.3M.com

Less weight, same warmth● Stimulating fibroblast cells to

activate wound healing ● Increasing the production of

ATP, providing energy to restarttissue healing

● Increasing the blood andoxygen supply to wound beds

‘KFH Novo is a very cost-effectivesolution, and we expect signifi-cant demand from wound careprofessionals,’ Dr Henk Snyman,the firm’s CEO, pointed out.Distributors wanted: ‘There is agreat deal of interest from themedical community,’ Marc Dauwe,Director of Medical Affairs, con-firmed, adding that KFH is lookingfor specialist distributors (contact:[email protected]).


N E W SH Y G I E N E

The 7th Villacher HygienetagExperts from almost a dozen Europeancountries – including for the first timeRussia, Bulgaria, Serbia and Croatia – willmeet at the Villacher Hygienetag (HospitalHygiene Congress) in October to discuss‘Antibiotic resistance – development,consequences and concepts’.

20 presentations and discussion rounds will tryto find answers to why the antibiotics andother agents developed to vanquish viruses andbacteria also made the organisms stronger.

ESGE-ESGENA2008 Guideline update oncleaning and disinfection ingastrointestinal endoscopy

Ulrike Beilenhoff,President of theEuropean Society ofGastroenterologyand EndoscopyNurses andAssociates(ESGENA)

Endoscopic procedures, which arewell established in the diagnosisand therapy of gastrointestinaldiseases, not only carry proceduralrisks but also the risk ofendoscopy associated infections.These include: ● Endogenous infections ● Exogenous infections caused by

inadequately reprocessedequipment from one patient toanother

● Risk of infection to staff workingin endoscopy

Appropriate reprocessing offlexible endoscopes andendoscopic accessories is anessential part of safety and qualityassurance in gastrointestinalendoscopy.

Since the late 1970s there havebeen sporadic reports ofnosocomial infections linked toendoscopic procedures. Theseinclude bacterial infections causedfor example by Salmonella spp,Helicobacter pylori andPseudomonas spp, as well asviruses such as Hepatitis B and C .The majority of documented caseswere due to non-compliance withnational and internationalreprocessing guidelines.

Since 1994, the ESGE-ESGENA*Guideline Committee hasdeveloped a number of guidelinesfocused on hygiene and infectioncontrol in Endoscopy (seewww.esge.com orwww.esgena.org).

This year, the Committee hasupdated the current guideline onreprocessing of flexibleendoscopes and accessories. Itaddresses several importantaspects of safety in gastrointestinalendoscopy. In addition to generalstatements, the guideline providesdetailed technical protocols for thedaily work of medical staff as thereare multiple local variations in theapplication of general guidelines.The consensus guideline has beenprepared by endoscopists,microbiologists, hygienists,endoscopy nurses, andrepresentatives of the biomedicalindustry.

In 2007, two guidelines werepublished that also address thenecessity of hygiene control in GIEndoscopy: ● ESGE-ESGENA Guideline for

process validation and routinetesting for endoscopereprocessing in washer-disinfectors, according to theEuropean Standard EN ISO15883 parts 1, 4 and 5

● ESGE-ESGENA Guideline forquality assurance inreprocessing: Microbiologicalsurveillance testing in endoscopy

These two guidelines must betaken into account whenestablishing local qualitymanagement of hygiene andinfection control in Endoscopy.

The ESGE-ESGENA guidelinescan be adapted locally to complywith national laws and regulations.

Source: Ulrike Beilenhoff/ESGENA

* ESGE - European Society ofGastrointestinal Endoscopy

The broad range of topics covers:● inter alia infection risks after natural disasters● sources of infections in hospitals, a look at the

relationship between nursing staff andphysicians from a sociological point of view

● the applicability of aviation safety strategies tohealthcare

● the economic aspects of improved hospitalhygiene will also be discussed.

Conference languages: German, English, Italian, withsimultaneous interpreting.

Villach,Austria

15-16 October2008


H Y G I E N E

Company Page Products

Edan Instruments 21 Medical equipment

GE Healthcare 7 Imaging

Inverness Medical 13 Diagnostic products

Maquet Critical Care 3 Intensive care

Medica 24 Medical trade fair

Meiko 23 Hygiene

Ningbo David 19 Neonate medical equipment

Richard Wolf 17 Endoscopy

Shenzhen Emperor Electronic Technology Co. Ltd 1 Ultrasound

Shenzhen Well.D Electronics Co. Ltd 11 Ultrasound

Siemens Healthcare 5, 9 ImagingAD

VE

RT

ISE

RS

IN

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The Thermologger

The remote monitoring of theoperating status of automaticbedpan washers has become pos-sible with the launch of theThermologger, made by Meiko.This new technology complementsthe firm’s cleaning and disinfec-tion appliances, which also haveintegrated control and measuringsystems.

Current DIN 15883 standardsgoverning the functional capabili-ty of medical devices (the catego-ry in which Meiko bedpan washersbelong) require tri-annual compli-ance validation and documenta-tion. Its service package coversthis task, Meiko points out. ‘A spe-cially-developed process guaran-tees maximum efficiency and safe-ty with a minimum of effort. Atemperature logger is attached bya holder in an optimum positionon the sanitised item. During thewash cycle a continuous stream oftemperature data is wirelesslytransmitted at a logging intervalof one second. At the end of eachequipment test, a set of DIN-com-pliant documentation is generatedand sent to the customer in PDF

file format. Obtaining a validationcertificate has never been easier.The service package also providesthe customer with all the relevantdata for his appliance logbook.’

The logger wirelessly transmitsdata from inside the machine to areceiver. Should the logger detectan irregularity, e.g. temperaturefluctuation, a service techniciancan remedy the fault immediately.

This new temperature measur-ing technology, which was devel-oped by Meiko with measurementspecialists ebro, means that noadditional monitoring, includingthe microbiological inspection ofthe appliances, is necessary. ‘Thetemperature logger measures andmonitors the temperature profile,which correlates with the microbi-ological destruction of pathogenicorganisms,’ Meiko explains.

Additionally, data from themachine and logging are storedwith the appliance’s serial number– providing users with informationon the life expectancy of themachine, to meet logbook require-ments at all times.Details: www.meiko.de

Belgium – Since 1988, all general hospi-tals are legally required to collect quar-terly data for a Nursing Minimum DataSet (NMDS). The NMDS was revised from23 to 78 items in 1997.

Imelda Hospital, in Bondheiden, one ofthe first hospitals there to implementPACS, was also among the first to imple-ment Agfa Healthcare’s Orbis Care sys-tem. This went live last November. Sincethen, over 15,000 nursing documentationforms have been registered electronical-ly in Orbis. In a second phase (comple-

NOSOCOMIAL INFECTIONS IN THE USABy Cynthia E Keen

As nosocomial, or healthcare-relatedinfections (HAIs), continue toescalate in the US, and protocols tomanage this problem remaincomplex and confusing, surveillancehealthcare IT systems offer hope togain control of the situation. Theseoffer the potential for data to beuniformly collected, quantified, andassessed. How rapidly they will beimplemented enough is unknown.

The Centres for Disease Controland Prevention (CDC) believe thatHAIs are one of the top ten causes ofunnecessary death in the US.According to a study published inNovember 2007, infections causedby staphylococcus aureus alonehave increased by 7% annually from1998-2003. In 1998, US hospitalsreported approximately 250,000staph infections; in 2003, nearly390,000, the equivalent of 1% ofhospital in-patient visits. Butbecause no standard methodologieshave been established to acquiremeaningful data, the numerousstudies to quantify the cost of HAIsdiffer dramatically.

Lead author Dr Gary Noskin, ofNorthwestern Memorial Hospital inChicago, estimated that the cost totreat staph infections aloneincreased from $8.7 billion in 1998 to$14.5 billion in 2003. His source ofdata originated from a NationalInpatient Sample Databasecontaining data from seven millionannual patient visits.

A study by University of Alabamaresearchers (pub: Medical Care.1/08) utilised data from over1,300,000 hospital admissions to 55hospitals for a five-year period (2001-2006). The hospitals wererepresentative in size of the mixtypical throughout the US, from 50 to1,000 beds, located in urban,suburban and rural communities.

Data, including actual hospitalcosts had been uniformly collectedby a healthcare IT data analysiscompany. Using this database, it waspossible to determine accurately thenumber of HAIs and their cost in2007 dollar values.

A total of 58,381 (4.3% of the total)infections were identified. Out of99,445 re-admissions of previouslyhospitalised patients, 7,501 were dueto an infection acquired during theprevious stay.

The additional average total costrelating to the infection was $7,007in added variable cost, $12 in addedtotal cost, and 5.4 extra in-patientdays. The majority of infections wereurinary tract (32.4%) costing $3,936,blood (21.5%) costing $12,774,respiratory (18.3%) costing $24,408and wound (14.3%) costing $7.059.

Clearly, the cost to treat HAIinfections is a huge waste and atravesty as the cost of US healthcaretreatment continues to soar. As ofOctober 2008, Medicare, which paysfor the healthcare of 43 millionpeople over aged 65, has stated thatit will stop reimbursing hospitals for

three types of preventableinfections, which include urinaryand vascular catheter infections.This will have a ripple effect,because US healthcare insurancecompanies typically follow the leadof Medicare.

New GAO report criticisesfederal health agenciesIn April 2008, the GeneralAccounting Office (GAO), the‘watchdog’ over US federalagencies, issued a report aboutinfection control to Congress. Thisdetailed how four different USagencies within the Health andHuman Services Department (HHS)all collect data, but collect differenttypes of data about differentsubsets of patients. About 500hospitals report data on infectionrates. 14 states require that data bereported to HHS and 16 states havelegislation pending to do so.

The GAO’s very critical reportstated that none of these agencieswere taking any steps to integrateany of the data from the four hugedatabases or communicateeffectively with each other. Thereport concluded that ‘HHS couldnot use its databases to providereliable national estimates of HAIrates, even for the selected types ofHAI being monitored, because noneof the databases collect data on theincidence of HAI for a nationallyrepresentative sampling ofpatients.’

The GAO identified over 1,200recommended practices to befollowed by hospitals, clinics, andlong-term care facilities to preventinfection. 500 of these are stronglyrecommended. The GAO pointedout that this huge number hashindered efforts to promote theirimplementation, and recommendedthat realistic priorities beestablished that can be reasonablyfollowed.

MRSAAccording to the respected Societyfor Healthcare Epidemiology ofAmerica, antibiotic-resistant MRSAacquired in the community isincreasingly the cause of infectionstransferred to hospitals. The drugcorporation Pfizer, Inc. estimatesthe nationwide cost for MRSA-hospitalised patients to be $3.2-$4.2billion.

In Illinois, New Jersey andPennsylvania, state legislationrequires that high risk patients andthose in ICUs be tested for MRSA.At least eight other statelegislatures are debating this.Testing of patients is a verycontentious issue, and has dividedthe medical community. Screeningis expensive. Opponents do notbelieve that screening and isolation

is preventing the spread of MRSA. Legislation was introduced in 2007

in the US Congress called the STAARAct to create an Office ofAntimicrobial Resistance, fundresearch, collect data and establishresearch. While many hearings havebeen held, it must be passed byAugust, due to election year politics,and controversy is associated withanimal-related provisions that maycause it to fail.

Surveillance ITMeanwhile, hospitals with electronicpatient records (EPR) areincreasingly starting to utilisecommercial healthcare ITsurveillance services. One suchservice, from Cardinal Health, uses aNonsocomial Infection Marker toprovide hospitals with a report ofHAIs by type and location throughouta healthcare facility and specificallyidentifies MRSA. By using specialiseddata mining and artificial intelligencesoftware, it constantly evaluates EPR

data in real time, and alertsadministrators to issues of concern orabnormal incidents indicative ofinfection outbreaks.

The software is similar to that usedby credit card companies to monitorpurchases for fraud, and identifiespatterns indicative of specific andcorrectable quality breakdowns.Cardinal Health states that itssoftware identifies clinically relevantissues that should be investigated,provides situation-specific, evidence-based practice recommendations, andprovides follow-up documentation ofthe corrective action’s impact basedupon the continuous monitoring.

This IT tool brings hope of anefficient means to fight infection inhospitals at its source. It would notexist without the infrastructure ofEPRs, and is still a relatively newtechnology. Combined with the old-fashioned remedy of repetitive handwashing, it seems to be one of the besttools available to help tackle this huge,expensive and dangerous problem.

Nursing documentation meets legal requirementstion: end of 2008) the NDMS and the Orbiselectronic care workflows will be integrat-ed.

Care Planning is also to be implementedwithin Orbis, where the captured data fromthe Nursing Documentation is immediatelyavailable for planning processes.Additionally, the patient chart, a tool toevaluate a patient’s status and adapt corre-sponding care planning in Orbis, will providenurses and physicians with a completeoverview of all necessary activities andobservations.

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The UK’s official 2007 MRSA ratesshowed that the Heart of England NHSFoundation Trust (HENHSF) hadreduced MRSA infections more thanany other Trust in the country. TheHENHSF award-inning Infection ControlTeam at Heartlands Hospital have cer-tainly neither been short on efforts orof ideas to reduce those numbers.

This May it was commended byEcolab, which produces Spirigel’s alco-hol gel, for using more of this productthan any other UK clients – 61,000 mlin 2007 compared to 5,000 ml in 2006.

During HENHSF’s two-week intensiveCleanyourhands campaign, inspired bythe film Ghostbusters, members of thepromotional team (pictured) mannedthe main entrance of the hospital wear-ing boiler suits and proton packs. Therethey gave visitors alcohol hand gel,urging them to use it upon entering thebuilding. Inside, visitors also foundposters, life-size cardboard models andeight foot display screens to remindthem, as well as patients, of how tocombat unwanted pathogens.

CHANGING CONCEPTS Killing MRSA bycurbing cannulae One highly notable development couldfind itself a paradigm to be adoptednationally and internationally.

Although in 2007-08 the Winchesterand Eastleigh Healthcare NHS Trust hadreported 11 bacteraemia infections (thegovernment’s maximum ‘acceptable’level is 12). Yet, in the last sevenmonths the Trust’s two hospitals havereported not one case of MRSA infec-tions, including bacteraemia andwound infections. Why?

Using long wave ultraviolet light theHand Inspection Cabinet (also calledthe Glow and Show machine) high-lights hygiene problems after washing,enabling infection control officers tohelp train staff in correct hand washingor scrubbing techniques. A lotion calledGlitter Bug, or a powder, is applied to


N E W SH Y G I E N E

French robots join UKbattleA small army of six robots (to be aug-mented by a cohort of six, in total cost-ing around €106,000) will soon arriveto emit a dry mist to attack any patho-genic micro-organisms in three hospi-tals in England’s Midlands.

A Norovirus outbreak in a ward atSandwell General Hospital lastDecember subsequently spreadthroughout the hospital. In April visi-tors to all adult wards (excluding pae-diatrics and maternity) had to bebanned. Stringent hygiene and a ‘deepclean’ followed.

After testing a Sterinis Robot on award, the NHS Trust responsible for thisand two other Midlands hospitals esti-mated it would take 16 of the robots toclean a single ward in two hours, butthey found the robot was also veryeffective in cleaning side rooms, baysand even ambulances. When the robotsarrive, the Trust plans to use them aswell as a deep clean.

Made by Gloster Santé, based inToulouse, France, the Sterinis Robotuses a patented dry-fog diffusion tech-nology to release particles of electrical-ly-charged ultra-high performancehydrogen peroxide (H2O2)-based disin-fectant. The particles stick to anything,the mist carrying them everywhere,onto curtains, beneath beds, into cup-boards, even concealed or inaccessibleareas, there to eradicate pathogenicorganisms, the firm reports, addingthat no room furnishings or equipmentneed be removed before a robot ‘inva-sion’. Such an onslaught is reported tobe effective in destroying MRSA, C Diff,e-coli, Norovirus, listeria, salmonella,etc.

Along with automatic monitoringand operating systems, which requireno human presence during the robotswork, the equipment also incorporatesa traceability system, so that disinfect-ing operations can be recorded and alog edited via the unit’s USB port.

The Sterinis process meets all therequirements of the Biocide DirectiveCE 98/8, Gloster Santé adds. ‘It is nei-ther corrosive nor toxic, and is 99.99%biodegradable.’

Glow and showinspection

Britain:The big bug busterBRENDA MARSH PRESENTS JUST A FEW OF THE TECHNOLOGIES ANDSTRATEGIES USED TO COMBAT DANGEROUS PATHOGENIC RESISTANCE

The UK’s MRSA rates have been declining since 2006 — and this yearcould be 50% lower than in 2004. This increasing control over dangerouspathogens has not been achieved without considerable hospital staffefforts, relentless public and government pressures on them, and in-housemalcontent about the out-sourcing of cleaning work.

Given the cost of nosocomial infections to patients, the NHS hasdeveloped many practices to be followed — for example operation ‘deepclean’ – and it spends a lot on developing various strategies, promotionsas well as equipment to promote more stringent hygiene. Here are just afew measures taken as well as debates currently in the UK news.

the hands and then washed off. Whenplaced in the cabinet any remaininglotion on hands fluoresces under theUV lamp.

Recently, Suffolk-based DaRo UVSystems Ltd redesigned this device. Themain body is now made in one-pieceand is no longer textured black, butnow a smooth metallic silver colour tomake lotion spills easier to wipe off. ‘Italso provides better light reflection forgreater disclosure of poor hand cleans-ing,’ DaRo says, ‘…and, it’s generallymore ascetically pleasing!’ adds DaRo.The larger viewing area also makestraining easier.

Among users for teaching purposes,Vicki Parkin, Head of Infection Controlat York Hospital — reported to havethe lowest number of outbreaks of sec-ondary infection (e.g. MRSA) in the UK– believes in the cabinet’s valuable.‘Every infection control unit must haveit, because it’s visually the only waypeople can see how easily infectioncan spread.’

Get the message?

Traditionally, new patients were auto-matically set up with cannulae for intra-venous injections. However, lastNovember a new procedure waslaunched in which only a doctor canprescribe cannula use and its insertionmust be performed only by trained spe-cialists. Once in situ the tube is flushedwith saline solution and then checkeddaily by a doctor, who records itsappearance and any irregularities.

Outsourcing must beoustedDespite the government giving hospitalcleaning high priority status and itsrecent implementation of a ‘deep clean-ing’ programme for all NHS hospitals inEngland, as well as its infection strategy(pub. January) that says quality cleaningis essential, a high number of doctorsand nurses are far from satisfied thatoutsourcing of ward cleaning andinstrument cleansing to private compa-nies works.Instruments - Currently, the govern-ment is encouraging NHS Trusts to useprivate decontamination centres forinstrument sterilisation. However, a sur-vey of surgeons, by the Royal College ofSurgeons of England (RCS) has revealedcountry-wide concern that some surgi-cal procedures have to be cancelled dueto problems with outsourcing. Twothirds of the 250 respondents said theywere unhappy about either the condi-tion of returned instruments (damage)or the lateness of their return — or evennon-return — from their out-sourcecentres.

ENT surgeon Professor RichardRamsden, who worked on the survey,emphasised that the study indicatesthat ‘…surgeons working with on-siteinstrument cleaning facilities are gettinga better service, enough to warrant anurgent reassessment of what’s best forthe NHS’.Ward cleaning – Back in the 80s, pri-vate cleaning firms began to receivehospital contracts. Today they undertakeabout 40% of NHS hospital cleaning.This is not satisfactory, said participantsat the recent Royal College of NursingConference, indeed for one the equationlooked straightforward: ‘There has beenan increase in hospital infections anddecline in cleanliness. It’s quite simple.’

The nurses blamed poor cleaningresults on a higher turnover amongcompany supplied cleaners, their lowtraining level and less commitment tothe hospital. In-house cleaners are morecommitted because they feel ‘part of theNHS family’ and ‘an essential part of theteam’, nurses pointed out. Another par-ticipant reported that NHS Trusts in thenorth-west has found their own answer:they are bringing cleaning back in-house. The nurses voted ‘overwhelming-ly’ for action to end cleaning contractswith private companies and bring hospi-tal cleaning back in-house generally.* The Department of Health has pointedout that there is no evidence of a differ-ence in quality, or infection rates, betweenhospitals with in-house or out-sourcedcleaning services.

Aneurin Bevan: What would he think today?

Hospitals with only singleen suite roomsIs this the answer?Medical professionals are hailing plansfor the new £53.7 million hospital inWales, to be named after the Welsh MPAneurin Bevan who became known asthe ‘Architect of the National HealthService’ after its launch 60 years ago.Due to open in 2011, the hospital willhave 96 en suite single-rooms. It willalso provide 11 adult mental healthbeds, 15 out-patient consulting rooms, aradiology department and a GP out-of-hours and minor injuries unit.Health Minister Edwina Hart said thesingle, en suite rooms will help to aidrecovery, improve privacy and reduceinfection risks. However, the RoyalCollege of Nursing commented that the

‘all single rooms’ policy would notprovide the full answer to infectioncontrol.Last autumn, the Health Ministerordered unannounced inspections oftwo Welsh hospitals with low hygienestandards. Among other measures, shesaid a group of health professionalswas being established to consider theenhancement and expansion of therole of hospital ward sisters, so thatthey would have more power overhygiene control.

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Nov. 19 –22, 2008

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Switzerland to adopt DRGs system - European Hospital

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