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Hw_1303_en (page 1)

for the World
Cutting-edge expertise in hygiene and infection control Issue 3 / October 2013 Brain games
It was no less a figure than Albert institution". The fact that there Einstein who said that creating is such a thin line between para- innovation requires ideas that noia and a healthy awareness of hygiene is something we often see When hygiene worries move beyond the realms of reason,
least at first. So in people who wash obsessively or paranoia is never far away. An interview with infection
why did the who refuse to leave the house with-founders of the out a bottle of hand disinfection control specialist and psychoanalyst Dr. Bodo Kirchner
lotion. As Dr. Bodo Kirchner explains in the interview on this page, one Our knowledge that hygiene can shift fluidly between anxiety, compulsion and hysteria is
of the most important tasks of people who work in the field of as old as our knowledge of hygiene itself. Dr. Bodo Kirchner used his presentation slot at
hospital hygiene is to always keep the Salzburg Hygiene Days to discuss what happens when hygiene moves beyond the
things in perspective. We can't see realms of reason. It's hard to imagine a medical professional better suited to addressing
a quote from bacteria, viruses, fungi and spores, this question and providing a few speculative answers. Kirchner is a specialist in internal
so we have to assess where they medicine, a general practitioner and an expert in geriatric, palliative, psychosocial and
are and remain vigilant at all times psychosomatic medicine. He is also a psychoanalyst and training analyst in the Salzburg
they like to think big – which is – but under no circumstances Psychoanalysis Study Group, as well as a psychotherapist, Balint Group Leader and
precisely what they should be should we lose our grip on reality.
doing. It's hard to imagine a group Supervisor. We spoke to this multifaceted medical professional – who also works as a
of infection control professionals This is a key point when it comes to hygiene specialist at the trauma hospital run by the Salzburg regional office of the Austrian
anywhere in the world that could providing people with information Workers' Compensation Board – and asked him whether hygiene can drive you mad.
match the combined expertise of on hygiene issues, as Chandrakant the people who regularly attend S. Ruparelia explains in an interview these kinds of conferences. One of on the back page of this issue of institutions falling into a the most prestigious attendees is "Hygiene for the World". To build Many hygiene specialists and classic trap. I remember a Dr. Elizabeth Bryce. Pursuing the awareness and provide develop- infection control experts end up situation in Austria where absurd was probably far from ment assistance in the realm of in their roles almost by chance, we would have had to her mind when she and her team hygiene, you need to have your feet often simply stepping in to a shut down the entire OR at Vancouver General Hospital planted firmly on the ground.
position that simply needs filling.
unit from one day to the in Canada decolonized patients Understanding how people "tick" Does the responsibility of what next if we had followed using nasal photodisinfection in order to give them appropriate the job entails affect people? to the letter the instruc- immediately prior to surgery and information on the importance of Or, to put it more provocatively, tions coming from top succeeded in significantly reducing disinfection, sterilization and hand how much psychosis or even management, which were the number of Staphylococcus hygiene is the key to intercultural neurosis do people develop in triggered by pure fear.
aureus infections (see article on cooperation. We hope to play a Ignorance is one of the key page 2 of this issue). She and her small part in achieving this with factors that fuels anxiety – team won the Innovation Award "Hygiene for the World". That's why Dr. Bodo Kirchner:
though it's equally true for their efforts – our heartfelt we put together this issue by There's no doubt that one of the that extensive theoretical congratulations once again! talking to people, asking them biggest challenges of this job is knowledge without prac- questions and presenting their to avoid becoming paranoid! tical experience can be just Flights into the realm of the absurd insights to you, all as part of our Obviously you become a lot more as dangerous. Sometimes are a common trait of patients efforts to encourage greater aware of the invisible dangers a lieutenant in the thick undergoing psychiatric treatment understanding of how hygiene, posed by the world of germs, but of battle knows more than – at least that's how it appears to emotions and innovation are all you have to maintain your ability a general stuck back at people "outside the walls of the to assess the risks realistically. Of Very best regards, Markus Braun course that's where you often get helping people to overcome flight That brings us nicely to the military, phobias by taking them up in a warlike imagery which so often plane. How can you help a patient Questions & Answers
crops up in the field of hygiene who has a phobia of germs? [2] Innovation award for
control: antibiotics as weapons, the Dr. Elizabeth Bryce and her team:
battle against germs, emerging Dr. Bodo Kirchner:
The infection control unit at Vancouver General Is there really no treatment for the pulmonary virus victorious from a major outbreak, Well, that pushes therapy to Hospital in Canada has won a prize for its ground- killer bugs and bacteria and so on.
its limits, because germs are breaking research. The team led by infection something we can't actually see! control specialist Dr. Elizabeth Bryce received the Dr. Bodo Kirchner:
You have to work with the imagi- award at the second ICPIC conference in Geneva Over 50 people so far have died of the new Our difficulty in recognizing and nation, for example getting the for a pilot project which involved treating patients coronavirus, MERS, with more than 110 infections identifying this "enemy" often patient to imagine touching a with nasal photodisinfection immediately prior to surgery.
confirmed. Since there is no direct treatment for leads us to associate it with evil door handle even though he or she the virus, patients are currently kept on organ intentions. Yet germs essentially is afraid that it's covered in germs.
[3] Salzburg Hygiene Days:
support in intensive care. But a trial involving have the same vital interests as The fear of infection is generally Gertie van Knippenberg-Gordebeke, the "Queen of monkeys has raised hopes that an initial treatment human beings. All this warlike very hard to treat. It poses similar Bedpans", recently ran a training session for approach may have been found.
imagery most probably stems from challenges to doctors as delusional student nurses. Her course for up-and-coming care the past, because people have parasitosis, where patients have professionals in Salzburg focused in particular Heinz Feldmann's team from the Rocky Mountain always fantasised about keeping a delusional belief that they are on learning the best ways to handle care utensils.
Laboratories in the US state of Montana infected things clean and pure. The idea that infested with parasites. You gene- six rhesus macaques. Three were treated with supposedly inferior beings pose a rally only get results by prescribing [4] His culture code: "Saving Lives".
a combination of the agents interferon alpha risk to things we consider superior additional psychotropic drugs to The international non-profit health organization and ribavirin. The three others were only given goes back a long, long way.
tackle the anxiety prompted by Jhpiego runs programmes in more than 50 placebo treatment. The animals receiving the real the delusions.
countries to prevent the needless deaths of women medication had no breathing difficulties, whereas and their families. We spoke to Chandrakant S. Ruparelia – a specialist in infection prevention the other monkeys did. Progression of the illness Patients suffering from anxiety and control at Jhpiego – about the importance in rhesus monkeys is similar to mild to moderately disorders can be treated through In your lecture at the Salzburg of "culture codes".
serious illnesses in humans. The medication is exposure therapy, for example Hygiene Days you talked about obviously most effective when administered soon exposing people who are scared of Obsessive Compulsive Disorder, [4] Masthead
after infection.
spiders to those very creatures or Continued on page 2


NEWS · NEWS
Innovation Award for Dr. Bryce
Bacteria inhibitor triclosan:
and Vancouver General Hospital
danger in toothpaste?
What does brushing your teeth have to do with bacterial resistance?
Quite a lot! Triclosan, the active ingredient used in toothpastes, is
Photodynamic therapy (PDT) tested at Vancouver General Hospital, Canada.
intended to combat gum problems, plaque and bad breath. However,Bo Jönsson – a Swedish professor of chemistry at the University of Dr. Elizabeth Bryce on behalf of VGH receives ICPIC award for pilot program
Lund – has observed that within just one week of using toothpaste containing this active ingredient, the triclosan reading in the urine "If at first, the idea is not absurd, then there is no hope for it. Innovation is not the product
to eliminate bacteria that are orthopaedic, thoracic, vascular, of the subject group had increased of logical thought, although the result is tied to logical structure." This quote from Albert
already resistant." breast reconstruction, and neuro- over a thousandfold. He therefore Einstein was selected as the motto of the 2nd Innovation Academy at the 2013 International
logical surgeries.
advises children and pregnant women Bryce and the team have success- to avoid toothpaste containing triclo- Conference on Prevention & Infection Control (ICPIC), which was held in Geneva. This year's
fully presented a business case A total of 40 teams took part in the san, as he fears it could have an innovation award was won by Dr. Elizabeth Bryce and her team from Vancouver General
to hospital managers demonstra- ICPIC innovation contest during the adverse effect on hormones.
Hospital which included specialists from the fields of infection control, quality & patient safety,
Salzburg Hygiene Days:
ting that incorporating decolo- conference in Geneva, which was surgery and medical microbiology.
nization in pre-op preparations initiated for a second time in June The German Federal Institute for Risk The accompanying prize of 10,000 risk of surgical site infection more Vancouver General Hospital. More yields significant cost benefits. For 2013 by Didier Pittet, Director of An enhanced profile and
Assessment's (BfR) attitude towards Swiss francs acknowledged the than ten-fold.
than 5,000 patients were treated example, the number of patients the Infection Control Programme triclosan is not quite clear. The Insti- team's work to prevent surgical with a combination of nasal readmitted with post-operative and WHO Collaborating Centre on tute has been advising against the use Foto: Vally – Fotolia.com site infections by conducting pre- The pilot program was conducted photodisinfection (the novel new surgical site infections fell to just Patient Safety at the University of an opportunity for carers
of triclosan in non-medical areas for years due to the possible deve- operative patient decolonisation.
over the course of 12 months at technology) and chlorhexidine 1.5 patients per month during the Geneva Hospitals.
lopment of bacterial resistance. The BfR, however, is not unduly con- body wipes during the study and pilot project, as opposed to the cerned about Bo Jönsson's research findings and refers to the appli- the number of post-surgical wound previous figure of four patients per The antimicrobial photodynamic of the future
cable pan-European triclosan limit values for cosmetics stipulated in infections was reduced by 42 month. The patients involved in therapy was developed by the the European Union.
percent. This has yielded multiple the study were admitted for major Vancouver-based company Ondine With its Salzburg Hygiene Days the Salzburg Hygiene The internationally renowned speaker, who is now benefits, as Dr. Bryce explains: surgeries including cardiac, spinal, Working Group (SAKH) has earned the reputation of a known as the "Queen of Bedpans", gave a presenta- "Thanks to this new method, conference organiser that likes to take a different tion on the work of a hygiene specialist as a "spider Hepatitis – an
Vancouver General Hospital saved approach to hygiene matters in order to broaden the in the web" at a hospital, as well as spending time 1.3 million Canadian dollars that perspective of its own work. The event took place in enthusiastically training young nursing students. "They it would normally have spent on Flu vaccine with
May this year for the seventh time. Looking back, are the future," said Dr. Markus Hell, explaining why treating the infections that would Dr. Markus Hell, specialist for hygiene at the Salzburg they had introduced an opportunity for future health- All five types of hepatitis virus have one otherwise have occurred." University State Hospital, was very happy with the care staff as part of the Hygiene Days.
ability to adapt
thing in common: they attack the liver cells response to the event and the fact that they achieved that they use to multiply themselves. The The multidisciplinary team notched an important objective: "We want to give the event a Using a bedpan washer provided by MEIKO, manufac- The main crux of the flu vaccine is that the pathogens of the
immune system can only fight the viruses up plenty of other impressive profile. On the one hand this includes a regional turer of cleaning and disinfection equipment, the flu virus constantly change. Having a vaccine that can quickly
by destroying infected cells. The result is results in the course of the year- catchment area, on the other we offer international dedicated Dutch expert showed the trainees how to adapt to viral mutations would be a highly practical solution
hepatitis. Hepatitis A and E are considered correctly load a cleaning and disinfection machine.
to the yearly vaccination programme against flu. It would be
to be less dangerous; infections with virus This year this once again included the Dutch hygiene But she also shared factual theory about bedpan a so-called recombinant flu vaccine.
types B, C and D, on the other hand, can Decolonizing a patient
specialist and proprietor of the consultancy firm washers and the risks involved in not adequately be critical. German experts are, therefore, calling for more intensive KNIP Consult, Gertie van Knippenberg-Gordebeke.
treating / incorrectly using care utensils.
to protect them
And this is exactly what has just been approved in the USA. According screening, as patients with the hepatitis-B or C-virus in particular,are usually only diagnosed by chance. Cancer of the liver is one of the from harm takes just
to the manufacturer, Protein Sciences Corporation, the innovative seasonal flu vaccine, FluBlok, has fifth most common cancers in the world.
a few minutes
one major advantage: the geneti- Foto: Eisenhaus – Fotolia.com cally engineered flu vaccine does The goodies and the baddies One of the ways infected patients excrete the hepatitis-A virus is in
not contain any complete viruses, their stool. Approximately 50 percent of infected patients develop long project. For example, the but rather only the glycoprotein jaundice. The illness usually cures itself without leaving any damage.
decolonization method employed these serious and chronic illnesses haemagglutinin, which in turn in intensive care
by the team is effective developing." Berg's researchers bears the main antigen structures The hepatitis-E virus is particularly prevalent in south east Asia, immediately and takes just took samples from 34 places in of the viral surface. What's more: Africa and central and south America and is transmitted through ten minutes to perform, Should we be questioning the
intensive care and "therefore, it has the intensive care unit of the the envelope of influenza A virus contaminated drinking water or food. There are no specific drugs as opposed to traditional existing hygiene and medical
to be as clean as possible there." Graz university hospital: from is 80 percent haemagglutinin. The to treat it.
methods of decolonization practices in hospitals? Is there
the floor, numerous workstations new vaccine can cover three of using nasal antibiotics for too much cleaning, disinfection
Professor Berg, on the other hand, and different medical equipment.
the currently relevant virus types: The hepatitis-B virus is extremely contagious. It is transmitted from five to seven days and chlor- and sterilisation? Researchers
quotes the warning of micro- They found bacteria which occur the influenza A strains H1N1 and person to person via blood, saliva and vaginal secretion. In adults the "Our method involves using nasal hexidine washes. According from the Technical and Medical
biologist Professor Dr. Martin ordinarily outside a hospital, as H3N2 and an influenza B strain.
disease passes in up to 95 percent of cases within three months. If the photodisinfection in combination to Bryce, a compliance rate University of Graz have studied
Blaser in her press release. He well as close relatives of potential infection lasts for more than six months it is referred to as chronic with chlorhexidine wipes for the of 94 percent shows that this the microbial inhabitants of an
is head of the Department of pathogens of human diseases – The World Health Organisation viral hepatitis. In 20 to 30 percent of cases, it can even cause liver rest of the body immediately new decolonization process intensive care unit in more
Medicine at the Langone Medical but they did also find many useful (WHO) stipulates the measures for cirrhosis. There is a vaccine against this virus.
prior to surgery," says Bryce, des- can easily be incorporated in depth. They concluded that not
Center of New York University bacteria. The researchers, however, selecting the virus types, and thus cribing the team's innovative the pre-operative prepara- only was there an unexpect-
and warned against the overuse also detected several subspecies of direct the vaccine manufacturers The hepatitis-C virus is primarily transmitted via blood and blood pro- approach. According to the hospi- tion of patients for surgery.
edly high number of different
of antibiotics. As far back as two propioni bacterium, pseudomonas towards the strains to be used for the following season.
ducts. 95 percent of those infected have no complaints and there is tal's microbiology experts, the types – some of them might
years ago he urged in an editor- and burkholderia bacteria – in total no direct correlation between infection and increased liver function method had a successful impact in Bryce is equally pleased with even be useful!
ial: "Stop killing useful bacteria!" they came across 405 genera from According to a press release by the US medical authority, the FDA, the readings. Hepatitis-C viruses can be completely eliminated from the 82 percent of patients colonized some of the other benefits: Blaser wrote an article on the seven different bacterial strains.
effectiveness of the recombinant vaccine was tested on a total of 2300 body, however the risk of chronic infection is high. 50 to 80 percent with Staphylococcus aureus in their Professor Dr. Gabriele Berg's subject in the "Nature" journal. He Americans in a placebo-controlled multicentre study. Approximately of those infected develop chronic hepatitis. The risk of developing nose. A propensity score analysis mic therapy does not cause team published its results in believes that destroying the pro- Another of their findings was that 45 percent of those vaccinated developed protective antibodies – cancer of the liver is roughly four percent.
that compared treated and untrea- microorganisms to develop "Scientific Report" and explained tective, friendly flora in the human genera that live on the skin were antibodies against all the strains of the virus in circulation at that, Hepatitis-D viruses can only be contracted by people already ted patients demonstrated that resistance – so that means in a press release: "Useful micro- body with antibiotics may be dominant on medical equipment not just the three whose proteins are contained in the vaccine.
infected with the hepatitis-B virus. If both infections occur, the decolonization therapy reduced the we can even use this method bes in hospitals combat potential even more dangerous to health and work surfaces. The researchers illness usually becomes serious. Drugs are only effective in roughly pathogens and should therefore than creating resistant microbes, expected this, because, after all, a quarter of patients.
or so-called "superbugs".
there are typically over 150 types Blaser continues in his editorial in of bacteria living on the palm of Continued from page 1 Brain games
the ground. They don't generally fit All you have to ensure is that the curing diseases, it also weakened However, Professor Dr. Christina "Nature": "Every child in the USA the human hand.
Most of the illnesses were caused They concluded that, "It is wrong the pattern of obsessive compul- compulsive aspects are kept in us by promoting selective pres- Wolz, who heads up a research and other developed countries by staphylococcus, E. coli, kleb- to immediately assume that bac- which revolves around fear of to offer a healthy dose of irony and sive people who enjoy tormenting check and do not develop into sure among bacteria.
group at the Institute for Medical receives on average 10 to 20 doses Berg and her colleagues reported siella, pseudomonas, serratia, teria in hospitals are dangerous dirt and infection and concepts of critical self-awareness! Because others! But of course dealing with hysteria or paranoia. You mustn't Microbiology and Hygiene at the of antibiotics before adulthood.
that a high percentage of the enterobacter, edwardsiella, pro- pathogens. Because the existing order, cleanliness, correct behaviour, yes, it's true that all these terms anxiety often requires a certain fall into the trap of believing Absolutist systems or forms of University of Tübingen, cast serious But these also kill friendly bacteria, bacteria were potentially human teus and chryseobacterium.
hygiene and sterilisation methods power, control, monitoring and essentially form the core duties degree of compulsive behaviour.
that this is a battle you can win.
hygiene fascism will never be the doubt on this argument: "This which may contribute to a rise pathogens, and they suspect that What Berg's researchers also found, don't distinguish between desira- punishment. Does that offer a of an infection control expert, in- way to win battles. And of course survey of the microbiome of an in obesity, allergies, asthma, in- the patients in intensive care however, were genera of bacteria ble and dangerous bacteria, we template for the ideal infection cluding the restrictive measures.
The fact that pilots are obliged to Whenever that delusion strikes, AIDS has taught us that the intensive care unit provides no flammatory bowel disease and contributed to the spread of the that can live in symbiosis with need to change our understanding But the hygiene specialists and work through a check-list before it's essential to remind ourselves problem is sometimes not the evidence whatsoever that hygiene type-1 diabetes. I think that doc- bacteria. The team compared the plants or can be used as probiotics of sterility and reassess current infection control experts that I take-off is a responsible and dili- that this battle is only just bacteria themselves, but rather practices should be changed." tors in the future will replace data with the infections recorded and prebiotics such as burkhol- hygiene practices in hospitals." Dr. Bodo Kirchner:
typically meet at conferences all gent way of dealing with the fear beginning. Penicillin didn't just the failure of our immune system Even non-pathogenic germs could the lost members of our natural during the time of the study and deria, pseudomonas, lactobacillus I certainly intended that question seem to have their feet firmly on of forgetting something important.
give us a stronger weapon for to find the right response.
be dangerous to patients in flora to reduce the chance of their suspicion was confirmed.
for the World
His culture code is:
"Saving Lives"
Dr. Chandrakant S. Ruparelia (pictured) – a doctor and Senior Technical Advisor at
the international health organization Jhpiego– is keen to give back to the people
something he himself received when he moved from his native India to America:
the chance of a better life. Jhpiego is a Baltimore-based, non-profit affiliate of
John Hopkins University that is working in more than 50 countries to prevent the
needless death of women and families. Ruparelia's family also lives in Baltimore,
but he spends most of his time travelling. He feels most at home on the African
continent, although he also occasionally works in India. His mission is to provide
assistance in situations where women and children are fighting for their lives,
whether in relation to HIV/AIDS, maternal and child health or infection prevention
and control. Jhpiego has spent 40 years focusing on its core mission of saving lives.
The ‘Hygiene for the World' editorial team spoke to Chandrakant Ruparelia about
his work and his organization at the ICPIC conference in Geneva.

Chandrakant S. Ruparelia:
Why does Jhpiego focus its efforts You were born in India and you You have to overcome signifi- respond to certain issues… can learn to help them practice primarily on women? Wouldn't it still do much of your work on the cant hurdles to achieve political hand hygiene even in these situa- make more sense to work on men's Indian subcontinent. There is a consensus, just like in almost every Chandrakant S. Ruparelia:
tions provided we know their issues since it tends to be the men huge variation in standards here other country. The only feasible Absolutely. If we are looking to culture code for hand hygiene.
in developing countries who wield nowadays, unlike in Africa. How strategy is to start at the point change people's behaviour in the power within families? does that affect your work? where a system really wants to regard to healthcare in a de- veloping country, then we need What is your personal culture Chandrakant S. Ruparelia:
Chandrakant S. Ruparelia:
to adapt our communication and It's true that we focus a lot of our We adapt the standards according our messages to their cultural efforts on helping women – for to the situations we encounter in One of your primary tasks is to code as effectively as possible.
Chandrakant S. Ruparelia:
example by providing information our work, but we still rigorously improve infection control proce- I would highly recommend reading Making a Difference and Saving on contraception, taking steps to pursue best practice based on solid dures. Are you also collaborating Clotaire Rapaille's book "Culture make birth safer, reducing infant scientific evidence. India has deve- with the WHO in this area? Code." He is an anthropologist and mortality and fighting against loped in leaps and bounds over marketing expert who has shown cervical cancer – but that doesn't the past 10 years, but there is still Chandrakant S. Ruparelia:
numerous companies why we live, imply that men don't benefit from an awful lot to do. As far as health- We're drawing on the WHO's tech- love and buy things in the way we our work, too. They are always nical guidelines to implement the do – and why other cultures do encouraged to make the most of standards, but that's essentially things completely differently! If that opportunity. We obviously also You can only make
true of all the countries where we we could apply that understanding 2-4 October 2013
need men to accept the work we progress if a system
work. The WHO always acts as our to our public health work and IFIC Buenos Aires, AR are doing to help women. We cons- technical partner.
development aid, we would un- really wants to change!
tantly need to find ways of getting doubtedly be more successful in 8-9 October 2013
them involved – that's a key part many of our efforts.
IHEEM Manchester, GB of what we do in all countries. In care and hygiene are concerned, You strive to build awareness, Nigeria, for example, we have used many private institutions have now encourage behavioural change and 10-12 October 2013
male health promoters to discuss achieved very high standards, and pass on knowledge through Train Could you give us an example? Congrès National Sapeurs- family planning issues with hus- it seems likely that public health- the Trainer courses, yet you have Pompiers Chambéry-Savoie, F bands and male relatives, and in care facilities will steadily follow.
expressed the opinion that you Chandrakant S. Ruparelia:
India, we targeted men as prime can only truly achieve useful Well, just think of the conditions recipients of family planning infor- results if you know how to deal in an Indian slum: How will 15-17 October 2013
mation, explaining how healthy How difficult is it to make progress with the "culture code" in each people accept your ideas on Pflege + Homecare Leipzig, D birth spacing benefits mother, baby in the field of healthcare in these particular country. I suppose you hand hygiene when they do not and the entire family.
need to know how people will have clean water to drink? We 23 October 2013
12th Hygiene Day Fürth, D
30 October - 1 November
"The standard of processing care
2013
IFAS Romandie Lausanne, CH
utensils is of huge importance!"
6 November 2013
From Geneva to Offenburg to Essen: this was the jour- Hygiene Symposium ney made by a delegation of ten infection control and hygiene specialists from Singapore. In Geneva the expertsattended the International Conference for Prevention & 20-23 November 2013
Infection Control (ICPIC). In Offenburg they visited the Medica Düsseldorf, D German manufacturer of cleaning and disinfection equip-ment, MEIKO, where they learned how the machines aremade. Gertie van Knippenberg-Gordebeke, who has spe-cialised in research and training regarding the correctuse of care utensils, also gave a talk for the visitors at MEIKO. Moi Lin Ling (Singapore General Hospital) con- cluded: "We still do not pay enough attention to howwe process care utensils. And yet the standard we app- Editorial team: Stargast Media ly to our work is of huge importance!" Gert Reiser (legally responsible for content), Doris Geiger And Lily Lang, hygiene specialist (Infection Control Nur- Klass Design (artwork) se) at the National Healthcare Group Polyclinic, concur- Reprint in whole or in part is prohibited red: "I myself had a British mentor in the 80s who except with written permission of theauthors and publisher.
emphasised the importance of paying attention to Hygiene for the World is published by care utensils. Today we use MEIKO appliances and MEIKO Maschinenbau GmbH & Co. KG the customised facilities in our utility rooms and the Englerstraße 3, 77652 Offenburg, interfaces of the equipment significantly contribute to patient safety as well as to our own safety."

Source: http://nl.meiko-bps.be/flashbook/hygiene/en/2013_03/files/assets/common/downloads/Hygiene.pdf

myastheniagravis.org

The Myasthenia Gravis Foundation of Illinois, Inc. August 2015 275 N. York Street, Suite 401 * Elmhurst, IL. 60126 * Phone: 1-800-888-6208 * www.myastheniagravis.org MG 101: What Every MG Patient Should Know Understanding how myasthenia gravis works and can be treated is important for every MG patient. Here is an opportunity to get a handle on myasthenia gravis

Doi:10.1016/j.jacc.2006.08.037

Journal of the American College of Cardiology Vol. 48, No. 11, 2006 © 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00 Published by Elsevier Inc. A Randomized Trial of CircumferentialPulmonary Vein Ablation Versus AntiarrhythmicDrug Therapy in Paroxysmal Atrial FibrillationThe APAF Study Carlo Pappone, MD, PHD, FACC,* Giuseppe Augello, MD,* Simone Sala, MD,*Filippo Gugliotta, BENG,* Gabriele Vicedomini, MD,* Simone Gulletta, MD,* Gabriele Paglino, MD,*Patrizio Mazzone, MD,* Nicoleta Sora, MD,* Isabelle Greiss, MD,* Andreina Santagostino, MD,*Laura LiVolsi, MD,* Nicola Pappone, MD,† Andrea Radinovic, MD,* Francesco Manguso, MD, PHD,*Vincenzo Santinelli, MD*Milan and Telese Terme, Italy