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AAGBI SAFETY GUIDELINE. Infection Control in Anaesthesia
- Leslie Robbins
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1 AAGBI SAFETY GUIDELINE Infection Control in Anaesthesia 2 Published by The Association of Anaesthetists of Great Britain and Ireland, 21 Portland Place, London W1B 1PY Telephone: Website: October 2008
2 Membership of the Working Party Dr Leslie Gemmell Dr Richard Birks Dr Patrick Radford Professor Don Jeffries CBE Dr Geoffrey Ridgway Mr Douglas McIvor Chairman, Honorary Secretary Elect President Elect Royal College of Anaesthetists Emeritus Professor of Virology, University of London Consultant Microbiologist Medicines and Healthcare Products Regulatory Authority Ex officio Dr David Whitaker Dr William Harrop-Griffiths Dr Iain Wilson Dr Ian Johnston Dr David Bogod President Honorary Secretary Honorary Treasurer Honorary Membership Secretary Editor-in-Chief, Anaesthesia This guideline was originally published in Anaesthesia. If you wish to refer to this guideline, please use the following reference: Anaesthesia 2008, 63;
3 Anaesthesia, 2008, 63, pages doi: /j x GUIDELINES Infection Control in Anaesthesia Association of Anaesthetists of Great Britain and Ireland Membership of the Working Party: Gemmell L, Chair; Birks R, President Elect; Radford P, Royal College of Anaesthetists representative; Jeffries D, National Institute for Health and Clinical Excellence; Ridgway G, consultant microbiologist; McIvor D, Medicines and Healthcare Products Regulatory Authority; Executive Officers of AAGBI, ex officio This is a consensus document produced by expert members of a Working Party established by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It updates and replaces previous guidance published in Summary (1) A named consultant in each department of anaesthesia should liaise with Trust Infection Control Teams and Occupational Health Departments to ensure that relevant specialist standards are established and monitored in all areas of anaesthetic practice. (2) Precautions against the transmission of infection between patient and anaesthetist or between patients should be a routine part of anaesthetic practice. In particular, anaesthetists must ensure that hand hygiene becomes an indispensable part of their clinical culture. (3) Anaesthetists must comply with local theatre infection control policies including the safe use and disposal of sharps. (4) Anaesthetic equipment is a potential vector for transmission of disease. Policies should be documented to ensure that nationally recommended decontamination practices are followed and audited for all reusable anaesthetic equipment. (5) Single use equipment should be utilised where appropriate but a sterile supplies department (SSD) should process reusable items. (6) An effective, new bacterial viral breathing circuit filter should be used for every patient and a local policy developed for the re-use of breathing circuits in line with manufacturer s instructions. The AAGBI recommends that anaesthetic departments should consider changing anaesthetic circuits on a daily basis in line with daily cleaning protocols. (7) Appropriate infection control precautions should be established for each anaesthetic procedure, to include maximal barrier precautions for the insertion of central venous catheters, spinal and epidural procedures and any invasive procedures in high risk patients Introduction The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines in 2002 on problems relating to infection control in anaesthetic practice. In addition to AAGBI Officers and Council members, representation included the Royal College of Anaesthetists and the Medicines and Healthcare Products Regulatory Authority (MHRA). This is an updated version of that guidance document. Healthcare organisations now have a legal responsibility to implement changes to reduce healthcare associated infections (HCAIs). The Health Act 2006 provided the Healthcare Commission with statutory powers to enforce compliance with the Code of Practice for the Prevention and Control of Healthcare Associated Infection (The Code). The Code provides a framework for NHS Bodies to plan and implement structures and systems aimed at prevention of HCAIs. The Code sets out criteria that mandate NHS bodies, including Acute Trusts, and which ensure that patients are cared for in a clean environment. Anaesthetists should be in the forefront of ensuring that their patients are cared for in the safest possible environment. Further advice can be obtained from the Department of Health (DOH) website clean-safe-care.nhs.uk. Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 1027
4 Infection control in anaesthesia Anaesthesia, 2008, 63, pages General principles Healthcare providers have responsibilities under the Health and Safety at Work Act 1974; offences against the Act are covered by Criminal Law. The Control of Substances Hazardous to Health (COSHH) Regulations 1999 have been considered part of the Health and Safety at Work Act; the Act ensures that Trusts are responsible for the health and safety of their employees and others (including visitors and patients), and the control and management of the risk of infection. As part of the Health Act 2006, the Department of Health (DOH) released the Code of Practice for the Prevention and Control of Healthcare Associated Infections [1]. Trust Chief Executives are accountable for ensuring that care delivered within each Trust meets relevant standards. Trusts should have Infection Control Committees and Infection Control Teams responsible for preparing policies and monitoring compliance with appropriate standards. A microbiologist should be designated to provide advice on microbiological aspects of decontamination and sterilisation. The AAGBI Working Party recommends that a named consultant in each Department of Anaesthesia should liaise with the Infection Control Team and the Occupational Health Department to ensure that relevant standards are established and monitored in all areas of anaesthetic practice. The environment Hospital environmental hygiene encompasses a wide range of routine activities that are important in the prevention of HCAI. The hospital must be visibly clean and acceptable to patients, visitors and staff. Statutory requirements must be met in relation to safe disposal of clinical waste, laundry and linen. Bed occupancy should ensure enough time between patient admissions to ensure adequate cleaning and decontamination of the patient area. The Code of Practice enshrines in law the duty of Trusts to maintain a clean and appropriate environment for patients including the fabric of the building and related structures. Operating theatres and associated areas should be designed and maintained to the standards defined in Health Building Note 26, Facilities for Surgical Procedures published in Microbiological commissioning and monitoring of operating theatre suites should adhere to national recommendations. Standard precautions Anaesthetists will be involved in the care of patients who may harbour potentially pathogenic organisms, which may not be obvious or readily identifiable. Precautions aimed at preventing the transmission of organisms between patient and anaesthetist or between patients must be a routine part of anaesthetic practice. The AAGBI recommends the use of Standard Precautions, which incorporate additional safeguards for specific procedures and patients, including single-use gloves, fluid resistant masks with a transparent face shield and gowns [2]. Precautions are recommended for all patients regardless of their diagnosis or presumed infectious status and must be implemented when there is a possibility of contact with: 1 Blood. 2 All other body fluids. 3 Non-intact skin. 4 Mucous membranes. Preventative measures should be based on the likelihood of an infectious agent being present, the nature of the agent and the possibility of dispersion, e.g. splashing. A standard set of precautions should be established for every invasive procedure (see below) with additional risk assessment of each patient to determine extra and specific precautions that may be appropriate. Hand hygiene Anaesthetists must ensure that good hand hygiene becomes an indispensable part of their clinical culture Hand-mediated transmission is the major contributing factor to infection associated with healthcare [3]. Effective hand decontamination immediately before every episode of direct patient contact will result in a significant reduction in the transfer of potential pathogens and a decrease in the incidence of preventable HCAI [4]. Despite consistent advice, staff often neglect hand hygiene when caring for patients. At the start of every session, and when visibly soiled or potentially contaminated, hands must be washed with liquid soap and water. When there is no soiling, the Hand Hygiene Liaison Group advocates that staff should use an antimicrobial hand rub between patients or activities [5] as this is effective and quicker. It is vital to ensure that the whole hand and fingers (particularly the tips), are exposed to the hand rub. Antimicrobial hand rub is not effective in preventing cross infection with Clostridium difficile. Trusts must ensure that sinks, soap and antimicrobial hand rubs are conveniently placed to encourage regular use. Watches and jewellery (including dress rings and wrist adornments) must be removed at the beginning of each clinical session, before regular hand decontamination begins. Cuts and abrasions must be covered with waterproof dressings, which must be changed as appropriate. Staff with dermatitis, psoriasis or other skin conditions should consult with the Occupational Health Department for further advice Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
5 Anaesthesia, 2008, 63, pages Infection control in anaesthesia The Code of Practice states that policies should be directly tied to the clinical governance framework and regularly reviewed under a system of audit, revision and update. Gloves It is important to undertake a risk assessment regarding the safe use of gloves. Although they may offer some protection against inoculation with blood-borne viruses, incorrect use of gloves could actually spread infection between patients. Sterile gloves must be worn for invasive procedures and contact with sterile sites. Non-sterile examination gloves must be worn for contact with mucous membranes, nonintact skin and all activities that carry a risk of exposure to blood, body fluids, secretions and excretions. All blood and body fluids, substances, secretions and excretions may be considered to be potentially infective regardless of the perceived risk of the source. Gloves must be worn as single-use items. They should be put on immediately before an episode of patient contact and removed as soon as the activity is completed, and before contact with fomites, including curtains, pens, clinical notes, keyboards and telephones. Gloves should be changed between patients and between different procedures on the same patient. Gloves must be disposed of as clinical waste and hands should be washed or decontaminated following the removal of gloves. It has been demonstrated that 98% of anaesthetists contact with patients blood could be prevented by routine use of gloves [6]. Gloves of an acceptable quality must be available in all clinical areas. Latex-free gloves must be available for use for staff or patients who have an allergy or sensitivity to rubber gloves. Facemasks The use of facemasks to decrease the incidence of postoperative wound infection has been questioned [7, 8]. However, masks with a face shield should be worn when there is a risk of blood, body fluids, secretions and excretions splashing into the face and eyes. Masks must also be worn by anaesthetists when carrying out a sterile procedure under full aseptic conditions (see later). If worn, masks should not be taken down to speak and should be changed if they become damp or contaminated. Masks must only be handled by the ties. Correctly fitting facemasks may also give some protection to the anaesthetist against inhaling infected droplets from the respiratory tracts of patients with infectious respiratory diseases. The Working Party is aware that the wearing of masks remains an area of contention in many Trusts and conflicting evidence may be cited [9, 10]. In view of the continuing controversy about the wearing of masks, the Working Party suggests that local protocols should be agreed about their use in hospitals. Theatre caps Theatre personnel in most UK operating theatres wear disposable headgear although there is little evidence for the effectiveness of this practice except for scrub staff in close proximity to the operating field [11]. However, theatre caps should be worn in laminar flow theatres during prosthetic implant operations, and it is the Working Party s view that their general use should continue. Theatre suits and gowns The skin of staff working in the operating theatre is a major source of bacteria that have the potential for being dispersed into the air. Clean theatre suits should be available for all staff in theatre. Full body, fluid-repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions. Sterile gowns should be worn when invasive procedures are undertaken. Disposable plastic aprons are often worn on wards in situations where there is a risk of physical soiling of clothing in order to prevent transmission of infection between patients. Contaminated clothing should be changed and safely discarded into an appropriate receptacle at the earliest opportunity. There is little evidence to show that wearing surgical attire outside the theatre and returning to the theatre without changing increases surgical wound infection rates. With the widespread move to admission on the day of surgery, the times when anaesthetists will have to leave theatre have increased and repeated changing will impact on theatre efficiency. Local policies must be developed and reflect the necessity for theatre discipline and allay perceived concerns of patients and visitors. Local policies should be agreed between all theatre users and Trusts must ensure adequate provision of appropriate clothing. The DoH guidance on Uniforms and Workwear [12] also recognises that there is little evidence that work clothes pose a significant hazard in terms of increased infection rates. Shoes and overshoes Special footwear should be worn in the operating department and cleaned if contaminated or after every use. Trusts should ensure that a system for cleaning theatre footwear is in place in each theatre suite. Plastic overshoes may increase bacterial contamination of floors [13] and, in addition, hands become contaminated when Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 1029
6 Infection control in anaesthesia Anaesthesia, 2008, 63, pages overshoes are put on or removed. Their use is not recommended. Movement within the theatre complex To reduce airborne contamination, general traffic in and out of the operating theatre itself should be kept to a minimum. Doors should be kept closed to ensure the efficiency of the ventilation system. Moving patients on their beds into the operating theatre may increase the bacterial count on floors, but it is claimed that this is of little significance if bed linen is changed before transfer [14]. All used linen must be handled safely to minimise the risk of contamination of the environment and staff. Used bed linen must be handled with care to reduce the release of small fomite particles into the air bed linen should be bagged by the bed or patient trolley. The use of separate trolleys from ward to transfer area and transfer area to table has not been shown to have benefit [15] although this practice continues in many operating areas. If entering the operating theatre itself, visitors should change into theatre suits and wear designated footwear. Order of patients There should be a written hospital policy requiring accurate printed theatre lists to be available prior to the scheduled date. Dirty cases, i.e. patients likely to disperse microbes of particular risk to other patients, should be identified before surgery and theatre staff should be notified. These patients should be scheduled last on an operating list to minimise risk. Where this is not possible, the Hospital Infection Society (HIS) advises that a plenum-ventilated operating theatre should require a minimum of 15 min before proceeding to the next case after a dirty operation [16]. The most probable routes for transmission of infection between successive patients are airborne or on items and surfaces that have been in contact with the patient. Appropriate cleaning of the operating theatres between all patients should be undertaken. Whenever there is visible contamination with blood or other body materials, the area must be disinfected with sodium hypochlorite (according to local protocols) and then cleaned with detergent and water. Floors of the operating room should be disinfected at the end of each session. Safe use and disposal of sharps Accidental injury has long been recognised as an occupational hazard in the healthcare setting. Accidental inoculation with infected blood, however small in amount, presents a significant risk to anaesthetists. In the UK, 16% of occupational injuries occurring in hospitals are attributed to sharps injuries. These are predominantly caused by needles and are associated mainly with venepuncture, administration of intravenous drugs and recapping of needles. These should be preventable by adhering to national guidelines and agreed standards [17]: Sharps must not be transferred between personnel and handling should be kept to a minimum. Needles must not be bent or broken prior to use or disposal. Needles and syringes must not be disassembled by hand prior to disposal. Needles should not be recapped or resheathed. Used sharps must be discarded into an approved sharps container at the point of use. The sharps container should be sealed and disposed of safely by incineration when about two-thirds full or in use for more than four weeks, whichever is sooner. Sharps containers must comply with BS 7320:1990 Specification for sharps. Blunt aspirating needles should be used for drawing up drugs. Needle protection devices may reduce needlestick injuries but require further evaluation before widespread use can be advised. Preventing contamination of drugs Drugs and fluids require safe handling by anaesthetists, who should follow local protocols for preparation and administration to prevent contamination. Syringes and needles are sterile, single-use items and, after entry or connection to a patient s vascular system or attachment to infusions, a syringe and needle should be considered contaminated and used only for that patient. A syringe must not be used for multiple patients even if the needle is changed. Before use, prepared syringes and needles should be stored in a clean container and syringes capped to avoid contamination. After use or at the end of the anaesthetic, all used syringes with needles should be discarded into an approved sharps container. Care must be taken when drawing up drugs. Single use ampoules should be discarded after the required amount of drug is drawn up and not re-used for subsequent patients. Ampoules can be kept for identification purposes and discarded at the end of the list. Multiple-use ampoules are not recommended. All infusions, administration sets or items in contact with the vascular system or other sterile body compartments are for single-patient use. An aseptic technique should be used when preparing infusions and breaks taps in lines should be kept to a minimum. Injection ports should be maintained with a sterile technique, kept free of blood and covered with a cap when not in use Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
7 Anaesthesia, 2008, 63, pages Infection control in anaesthesia Connections and injection ports in intravenous lines should be kept to a minimum. Three-way taps should be avoided if practicable. Needle-free Luer injection devices should be used to cover exposed female Luer injection ports. These are easily cleaned before and after drug administration, do not harbour blood in crevices and also reduce the need for needles, resulting in a reduction of needlestick injuries. infection. Guidance on Decontamination prepared by the MHRA and DoH provides guidelines for the safe reprocessing of medical devices [19, 20]. It is recommended that each department identifies a designated consultant who, in conjunction with the appropriate bodies in their Trust, will develop specific guidelines for anaesthetic practice which satisfy national recommendations and that these practices are audited on a regular basis Anaesthetic equipment and infection control Items of anaesthetic equipment may become contaminated either by direct contact with patients, indirectly via splashing, by secretions or from handling by staff. Contamination is not always visible and all used pieces of equipment must be assumed to be contaminated and disposed of or, if reusable, undergo a process of decontamination. The Code of Practice has specific requirements for the decontamination of surgical equipment and other equipment used in patient care. There is a need to designate a person who is responsible for ensuring equipment cleanliness. Single-use equipment Where appropriate, single-use disposable equipment will remove the difficulties of re-use and decontamination procedures. The use of such equipment is to be encouraged. However, there are problems of cost, storage and disposal of single-patient use devices, and for some equipment there is no feasible disposable alternative. The balance between single-use items and re-usable equipment will require local determination based on an assessment of patient safety, the available facilities and cost. Packaging should not be removed until the point of use for infection control, identification, traceability in the case of a manufacturer s recall, and safety. A multidisciplinary research team at the University of Nottingham has carried out a study investigating the use and re-use of single-use devices in English NHS operating theatres. The published paper clarified some of the issues around single-use devices such as single-use equipment that must be immediately discarded after use, e.g. suction catheters, and some that may be re-used in the same patient in the same episode, e.g. disposable laryngoscope blades [18]. Decontamination Decontamination is a combination of processes including cleaning, disinfection and or sterilisation used to make a re-usable item safe to be handled by staff and safe for further use on patients. Effective decontamination of re-usable devices is essential in reducing the risk of Decontamination processes Cleaning removal of foreign material from an item. This usually involves washing with a detergent to remove contamination followed by rinsing and drying. All organic debris, e.g. blood, tissue or body fluids, must be removed before disinfection or sterilisation, as its presence will inhibit disinfectant or sterilant from contacting microbial cells. Cleaning before sterilisation is of the utmost importance in the effectiveness of decontamination procedures in reducing the risk of transmission of prions. Low Level Disinfection kills most vegetative bacteria (except TB and endospores), some fungi and some viruses using disinfectants such as sodium hypochlorite, 70% alcohol and chlorhexidine. High Level Disinfection kills vegetative bacteria (not all endospores), fungi and viruses. With sufficient contact time (often several hours), these high level disinfectants may produce sterilisation, e.g. the use of aldehydes, peracetic acid and chlorine dioxide. Sterilisation A process used to render an object free from viable micro-organisms, including all bacteria, spores, fungi and viruses, with techniques such as autoclaving (but see prions later). Risk assessment The choice of equipment and or the level of cleanliness disinfection sterility required of re-usable items may be assessed against the risk posed to patients of transmission of infection during any procedure in which the equipment is employed. It has been proposed by the MHRA Microbiology Advisory Committee that three levels should be considered: 1 High Risk the device will penetrate skin or mucous membranes, enter the vascular system or a sterile space these devices require sterilisation. 2 Intermediate Risk the device will be in contact with intact mucous membranes or may become contaminated with readily transmissible organisms these devices require high level disinfection or sterilisation. Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 1031
8 Infection control in anaesthesia Anaesthesia, 2008, 63, pages Low Risk the device contacts intact skin or does not contact patient directly these devices require low level disinfection or cleaning. Infection control policy Anaesthetic face masks Although normally in contact with intact skin, these items are frequently contaminated by secretions from patients and have been implicated in causing crossinfection [21]; local disinfection is not normally effective. These items should be single-use items or should be sterilised between patients by an audited Sterile Supplies Department in accordance with the manufacturer s instructions. Airways and tubes Oral airways, nasal airways and tracheal tubes should be of single-use type since they readily become contaminated with transmissible organisms [22] and blood [23]. Ideally, supraglottic airways should be of the singlepatient use type but the re-usable design is in common use and many anaesthetists perceive it as being less traumatic. Therefore, a supraglottic airway designed for repeated use should be sterilised (in an audited SSD) no more often than the manufacturer recommends. A supraglottic airway used for tonsillectomy or adenoidectomy should not be used again (see section on Prion Diseases). The AAGBI recommends single-use supraglottic airways. Catheter mounts angle pieces It is recommended that these items are single-patient use type. Anaesthetic breathing systems The AAGBI has previously recommended that an appropriate filter should be placed between the patient and the breathing circuit (a new filter for each patient). Although it appears that pleated hydrophobic filters have a better filtration performance than most electrostatic filters, the clinical relevance of this has yet to be established [24, 25]. The MHRA have also warned of the difficulty in assessing the performance of breathing filters in MDA Until 2001 manufacturers of disposable anaesthetic breathing circuits supplied these as non-reusable items. In practice, most UK departments of anaesthesia used these circuits for more than one patient or for more than one operating session in conjunction with the use of a new filter for each patient. In 2006, the MHRA re-emphasised in Devices Bulletin DB 2006(04) the clinical and legal implications of re-use of devices labelled for single use and the AAGBI firmly supports their recommendations. Therefore, departments may follow the manufacturer s recommendations for use for up to 7 days. However, to ensure consistency in the infection control process, the Working Party recommends that circuits are disposed of when the anaesthetic machine and monitors are cleaned (see below). The AAGBI recommends that anaesthetic circuits are routinely changed on a daily basis. If visibly contaminated or used for highly infectious cases, e.g. tuberculosis, the circuits should be changed between patients and safely discarded. No attempt should be made to reprocess these items. Anaesthetic machines Routine daily sterilisation or disinfection of internal components of the anaesthetic machine is not necessary if a bacterial viral filter is used between patient and circuit. However, manufacturers cleaning and maintenance policies should be followed, and bellows, unidirectional valves and carbon dioxide absorbers should be cleaned and disinfected periodically. All the surfaces of anaesthetic machines and monitors should be cleaned on a daily basis with an appropriate disinfectant or immediately if visibly contaminated. Laryngoscopes As with anaesthetic facemasks, laryngoscopes are known to become contaminated during use. Current practices for decontamination and disinfection between patients are frequently ineffective, leaving residual contamination that has been implicated as a source of cross-infection [26, 27]. Blades are also regularly contaminated with blood [28], indicating penetration of mucous membranes, which places these items into a high-risk category. Proper cleaning of laryngoscope blades is of great importance before decontamination sterilisation, particularly of residue around light sources or articulated sections. New purchases should be of a design that is easy to clean. Although repeated autoclaving may affect the function of laryngoscopes [29], the Working Party recommends that re-usable laryngoscope blades should be sterilised by an audited SSD between patients, following the manufacturers instructions. Plastic sheaths may be used to cover blades and handles to reduce contamination but it has been noted, especially with blade covers, that these have created difficulties during tracheal intubation. There are an increasing number of inexpensive, singleuse laryngoscope blades and handles of improving design available, and their use is to be encouraged. The choice of blade must be dictated by Departments of Anaesthesia Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
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Mayor Judy Cox pitched her idea to the village council at the Nov. 21 meeting after she learned how Sugar Creek Township plans to provide fire and EMS protection for its citizens.
Current subscribers have full access to all online news content as part of their subscription. If you are a current subscriber, please log in with your website account information for full access. If you are a current subscriber, but have not yet registered for access to the website, please call our Circulation Department at (330) 287-1615

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A3C Festival,
A3C Presents,
ATL's Own,
Mobb Deep
This summer, A3C is giving you a chance to get in front of the team that launched the careers of Trinidad James, Rich Homie Quan, & YFN Lucci with four unique experiences at select Boost Mobile...Read more
We want to celebrate July 4th by calling for ACTION! The urgency of today demands us to be vigilant and pro-active. Words, posts, RTs, and comments are not enough. Nas recently...Read more
Fool's Gold DAY OFF is taking over A3C Festival on Sat, Oct 7 with A-Trak, DJ Drama & Don Cannon, Zaytoven, Smino, Kodie Shane, Maxo Kream, Wifisfuneral, Hoodrich Pablo Juan, ManMan Savage, Nick...Read more
Explore the initial group of industry experts, trailblazers and innovators speaking at this year's A3C Conference - Steve Rifkind, MC Lyte, A-Trak, DJ Drama, Don Cannon, Sonny...Read more
We've partnered with B.o.B, BeatStars & Native Instruments for the official Remix Competition for one of our personal favorite tracks off Ether, "Middle Man." Purchase Ether on iTunes Atlanta...Read more
1-Day Festival passes are on sale for ONLY $39 ... while supplies last. The A3C Festival is a 2-day hip-hop festival in the heart of downtown Atlanta outside the Georgia Freight Depot on Sat, Oct 7...Read more
The BeatStars Summit @ A3C Conference will focus on empowering producers and beatmakers to become entrepreneurs and create new revenue streams. Network with peers and hip-hop's most influential...Read more
Applications for the 3rd annual A3C Action Pitch Competition are now open. The A3C Action Pitch Competition is a national competition to find,...Read more


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New and returning customers : securely link to mm.loccitane.com with your preferred social network and share one login for both!
Enriched with 20% Shea Butter, this super-creamy balm penetrates quickly to protect, nourish and moisturize* hands. Honey, almond extracts and coconut oil are blended with Shea Butter to create this extremely effective care. The rich texture is rapidly absorbed to leave the hands soft and smooth with no oily traces.
Apply day and night as needed.
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Who Wants Pizza?
From 9 to 13 | 64 pages
Often, food is something that kids take for granted. For many, it simply shows up for them every day — thanks to their parents. But there is so much to know and understand about food. Why do we need to eat? Where does our food come from? Is there enough food for everyone?
Award-winning author Jan Thornhill answers all these questions and more in Who Wants Pizza? Using one of the most common foods that kids eat — pizza — as a jumping off point, and, using a bold, graphic approach, Thornhill take an extraordinary and comprehensive look at some of the following topics: Why we eat and why we eat what we eat, how we moved from eating the raw flesh of animals to becoming sophisticated consumers of food, how food is produced for an ever-growing population, and more.
It may seem like a lot to swallow, but the text is delivered in bite-sized bursts and complemented by tons of interesting facts, photos, and illustrations to ensure kids are captivated by the information. Plus, no book about food would be complete without touching on things like burbling stomachs and human waste — the gross stuff that kids love to learn about. Comprehensive, eye-opening, engaging, and fun, Who Wants Pizza? will be a book that kids will want to digest again and again — figuratively, of course.


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Sorry, we only have of these items available. We have reduced your order quantity to
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Please enter a number for the value
Sorry, you can purchase one of these items per product
Photograph by Peter Jeffree
Brent Cross Shopping Centre
020 8202 6535*
*Call charges will depend on your provider, please check with your operator
|10am - 8pm
(Bank holidays 10am-8pm)
|10am - 8pm
|10am - 8pm
|10am - 8pm
|10am - 8pm
|9.30am - 7pm
|12noon - 6pm
(browsing 11.30am-12noon)
Brent Cross is situated close to several major trunk routes including the M1, A41, A5 and the A406, London`s North Circular Road. It is easily reached from the M25. Free car parking is provided.
Buses arrive at the bus station on the south side of the Centre. Green Line buses stop on the North Circular Road. The following routes serve Brent Cross shopping centre: 102, 112, 142, 143, 182, 186, 210, 232, 266, 326 and C11.
For visitors arriving by London Underground, the Centre is served by stations at Hendon Central and Brent Cross (Northern Line - Edgware branch)
Taxis are available throughout the day at the front of the Centre by the bus station. They can be contacted by phone on 020 8203 5470
For more information visit the Transport for London website
Why not use the Transport for London Journey Planner to help plan your journey? Enter where you're travelling from and it will show you how to get to John Lewis Brent Cross
Can't wait for delivery?
Why not try our Click & collect service?
Order by 8pm today and we'll deliver to your chosen shop for you to collect after 2pm tomorrow. Click & collect is free when you spend £30 and over, and costs £2 when you spend less
Our Customer collections point is on the First floor near the Home departments
Every Sunday afternoon we offer complimentary tastings of Coole Swan. Coole Swan is a tasty cream liqueur made with Irish whiskey, cocoa, vanilla and double cream.
The gentle melt in the mouth feeling of the cold, fresh, cream and smooth silky white chocolate reveals the warmth of the mellow, rounded whiskey.
Every Sunday, 12.30pm - 4pm
Gift Food, First floor
We're proud of the close links we forge between our Partners and local schools, charities and organisations. And wherever we do business, at home or abroad, we work with communities to make a difference. That's why:
If you'd like to nominate a good cause for Community Matters please complete the nomination form and take it to the Customer Services department.
The charities we've supported are:
To make a donation to Barnardo's, our 150th anniversary charity, and help support those UK children who need it most, please text JL [Enter your local shop name] to:
Since the introduction of the law requiring retailers to charge for single-use carrier bags, our charity, the John Lewis Foundation, has been responsible for distributing the proceeds to UK charities. We've aimed to choose charities closely aligned with the principles of the Foundation, supporting activities that promote education and inclusion, and enable employment. We're sharing the past year's proceeds of over £155,000 between six charities.
We'll collect and re-use your old sofa when you purchase a
new sofa from us


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HeartRise Meditation ~ The Den
HeartRise Meditation ~ The Den
Join Jessie May for HeartRise at The Den Meditation! Land your day with a nourishing, guided HeartRise journey & come home to your knowing heart. Through Jessie May's HeartRise Meditation, you'll learn to recalibrate your whole being through the powerful energy of your heart, with your breath. Soften your mind and let your heart lead, with this unique, transformational method sure to ignite you from the inside out. HeartRise Meditation will support you in all areas of your life, connecting you with the infinite wisdom and aliveness of your radiant heart. These signature sessions are unlike any other! Full house, candlelight, cozy community and connection. Be sure to book your spot as we fill the house.
Mondays at 9pm


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Just one of the interesting details from this informative interview about marketing on Facebook: This reminds me, please like Camels With Hammers on Facebook to stay caught up with us and help spread the word about the site to your friends! Your support or lack thereof makes or breaks a blog. Never underestimate your power [Read More…]
1/4 Of All Internet Time Is Spent On Facebook
February 2, 2011 by Leave a Comment
Like Camels With Hammers and Patheos Atheist on Facebook!


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This property is no longer available.Search for Available Property.
1.7 acres in Gwinnett County, Georgia
Excellent opportunity to acquire a building lot in much desired Dacula. Property can potentially be divided into two building lots or could potentially be rezoned for commercial use.
From Lawrenceville, Take 316 East, Turn Right On Harbins Road, 1.4 Miles Turn Right On W Drowning Creek Rd. .4 Miles Turn Left Onto Jordan Rd. .2 Miles Turn Left On Ewing Chapel Rd. 1.2 Miles Location On Left At Intersection With Brookes Road Se.
Tax Data (Show Tax Data)
Tax data is not available for this listing.
Contact the Seller for more information.
Other Land for Sale in Gwinnett County
NOTE: The information contained herein is provided as general information only and has been obtained from sources deemed reliable. It is provided without any guaranty, warranty or representation, expressed or implied, made by Lands of America, or any related entity, as to the accuracy or completeness of the information. The information is presented subject to errors, omissions, change of price or conditions, prior sale or withdrawal without notice. Prospective purchasers should make their own investigations, projections and conclusions concerning the information.


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A local SeoServicesUsa website explains how you can find the best museums with the help of search engine optimization.
Do you love to visit museums? If you love to explore museums and enjoy the exhibits within them, you may want to seek out new museums in your area.
What's the secret to finding great museums? Surprisingly, search engine optimization is one of the keys to discovering the best museums in your area. Here are a few tips that will help you to find the kind of museums you are interested in:
Search For New Museums Regularly
Search engines are regularly updating and improving their algorithms, which means that the results you receive from a search won't always be the same. If you seek out museums on a regular basis, you may see new museums appear in your search results.
Make a point of looking for museums regularly. A search can be completed in less than a minute. It won't take you much time to investigate the museums in your area.
Take Advantage Of Location-Based Searches
Make sure you allow search engines to detect your location when you are performing a search. If you do this, you will always be able to find the museums that are the closest to you. For example when you search on Google for "SEOservicesUSA – New York SEO Company" you'll get different results than just typing a single term.
This is a great way to find museums or anything you are searching when you are out of town. If you're away from home and looking for attractions to visit, location-based searches should allow you to find what you are looking for. You'll be very impressed when you see how many museums there are.
Use Different Keywords
When you're searching for museums, you shouldn't limit yourself to the word "museums." Instead, you should try to use different keyword phrases when you search.
Not all museums are the same; there are many kinds of museums out there. Use keywords that relate to the kind of museums that you want to find. Be as specific as you possibly can.
If you want to look at paintings or sculptures, you should search for art museums near you. You may want to add additional keywords that specify the type of art you are interested in. You could look for a classic art museum, a local art museum, a modern art museum, or another type of museum.
If you are interested visiting a science or a history museum, you should use keywords that relate to that. If you want to find a museum that is child-friendly, you should look for a children's museum.
If you're not finding the kind of museums that you want in your search results, you probably need to make some changes to your keyword phrases. As long as you make a few small tweaks, you should eventually get the kind of results that you are looking for.
Take Advantage Of Maps
Search engines now do a lot more than provide search results. Search engines can also provide you with maps. This will allow you to see exactly how close various museums are to you.
If your goal is to find a museum that is a short drive away, you should be able to do that. If you're trying to find a museum that is close to your work, you should be able to do that as well. Maps make it easy for you to determine exactly where the museums in your search results are.
A lot of museums are improving their SEO, which means it's easier than ever for you to find museums in your area. If you're interested in visiting a local museum, see what kind of results you get when you search for museums in your area. There's a very good chance that you will like what you eventually see.


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Fuck Off
The art and science of knowing when to fuck off and when to fuck yourself. Fucking off is an integral part of our daily lives. The important thing to understand here is that we fuck off from one place to another place. So for example today my professor
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Utforsk lignende emner
Stairway to Heaven, Valparaiso, Chile - ©Kurt Van Wagner (via FineArtAmerica)
Torres del Paine National Park, Patagonia, Chile. Den perfekten Reisebegleiter findet ihr bei uns: https://www.profibag.de/reisegepaeck/
The Ultimate Travel Guide To Chile
Use this list of 10 Best Places to Visit in Chile to plan your trip to this diverse country in South America - with personal tips and recommendations!
Termas Geométricas hot springs, Pucon, Chile l Photography by @seniorjp #destinationearth
Marble Caves of Patagonia in Chile – Lake Carrera. The lake is on the border of Argentina and Chile, and the caves are located on the side of Chile. The caves are the three main grotto: Chapel (La capillaries), Church (El Catedral) and Cave (Cueva). Visitors can explore the caves on a small boat or kayak, but only after the waters of Lake Carrera calm down and be serene.
Chile Travel Cheat Sheet; Sign up at www.wandershare.com for high-res images. #weddingdream123
Must sees in Chile
Puerto Varas, Chile
Montaña Mágica Lodge,Camino Internacional Panguipulli, Neltume, Chile


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We report on a diode-pumped tunable Yb:glass femtosecond laser oscillator with electro-optic cavity dumping. Pulses with energies exceeding 400 nJ and peak powers greater than 1 MW were generated at repetition frequencies as high as 200 kHz. This laser forms a compact light source for various scientific and industrial applications such as micromachining.
© 2004 Optical Society of AmericaFull Article | PDF Article
OSA Recommended Articles
Alexander Killi, Jochen Dörring, Uwe Morgner, Max J. Lederer, Jürgen Frei, and Daniel Kopf
Opt. Express 13(6) 1916-1922 (2005)
Chang-Ki Min and Taiha Joo
Opt. Lett. 30(14) 1855-1857 (2005)
Nickolai Zhavoronkov, Hiroaki Maekawa, Hiroaki Okuno, and Keisuke Tominaga
J. Opt. Soc. Am. B 22(3) 567-571 (2005)


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Change Currency
Antique quality 19C Regency, William IV or possibly early Victorian mahogany chiffonier sideboard cupboard.
Very rare and unusual with lovely proportions and styling.
Mirrored doors, with a little oxidation and some scratching to the glass.
No keys and the lock is untested.
This is a rare quality piece of antique furniture that would look great in the right location and is attractive/aesthetically very pleasing, with a great sense of grace and charm.
Overall dimensions 1330mmW x 460mmD x 930mmH (+500mmH back).
Historical knocks, marks, cracking, repairs and alterations, as is usual for an item such as this. There are historic repairs to the left hand scroll pilaster and in the hinge areas (as is common).
Stock No. 2441.
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Eventually, Norv Turner's offense will challenge defenses in the NFC North and beyond. For now, however, it is challenging his own players first.
Turner, the new offensive coordinator for the Minnesota Vikings, has a complex offense, according to veteran receiver Greg Jennings, who invoke hyperbole to make his point.
"The variations from one play to the variations of how we can get to that one play is a lot," Jennings said after a couple days immersed in the system. "I'm being a little sarcastic with this statement, but it almost equates to what we had last year. Just one play. It's a lot."
Obviously, that's not the case, but both Jennings and second-year receiver Cordarrelle Patterson talked about the vast differences between Turner's offense and what they both had to learn last year under then-coordinator Bill Musgrave. Both of them were in their first year with Musgrave last year, too.
"Yeah, it's totally different from last year. It's going to be tough, but us guys, we're going to work together," Patterson said. "We're going to be with each other, get here early in the morning leave late after practice. We're going to be with each other and get it done."
Of course, Turner's system has stood the test of time in the NFL.
It did that last year, too, on an individual basis and as a whole.
Last year, even with all their quarterback issues, the Browns finished 11th in passing offense under Turner. Receiver Josh Gordon went from 50 catches, 805 yards and five touchdowns before Turner to 87 catches, 1,646 yards and nine touchdowns with Turner. Tight end Jordan Cameron went from 20 catches, 226 yards and one touchdown in 2012 to 80 catches, 917 yards and seven touchdowns last year with Turner.
"Everybody is going to have an opportunity to showcase what they can do. That's one of the things he is spoken highly upon within our group. He's going to showcase what we do well as individual receivers as well as a unit," Jennings said. "And I think that's all you can ask for when you're in a position where you don't really get to dictate what happens. All you can do is run your route to the best of your ability and hope that you get opportunities to make plays. With what Coach Turner is bringing to the table, there are going to be a lot of guys that have a ton of opportunities to make plays. And if you look at his track record, the receivers and tight ends that he's had, and the running backs, they've all fared very, very well in his systems."
That's exactly what one of Turner's living examples, Josh Gordon, told Patterson when they talked at the Pro Bowl.
But just because that is the expectation doesn't mean getting to that point in four months is going to be easy. There is plenty to learn … and plenty to forget.
"Literally everything is different. The number system is completely opposite than the West Coast," said Jennings, who spent his first seven seasons in Green Bay's West Coast offense. "Obviously, the concepts, once they're in, they're similar. But the way those concepts are verbalized, the language is completely different. Literally I've had to erase everything that I've learned in the past and completely start from scratch, which is exciting because we're all in the same boat. Especially with what he brings to the table, the different variations, it's exciting.
"It can be overwhelming."
Jennings also described it as exciting. He and others believe that what they have to go through from a learning process for the next few months will be worth it once the season starts.
The players know all about Turner's credentials, and they are buying into the offensive coordinator because of his big helping of credibility.
"They weigh a ton," Jennings said of Turner's credentials. "What he says you can pretty much stamp it in concrete. He's one of those guys that's not going to give you a bunch of leeway because his offense works. It's proven and that's one of his statements he makes: 'Look guys, I've been around a little bit longer than most guys in this building and this has worked.' Now, he's very open-minded and willing to understand that, when putting things on the field, guys are going to run routes differently than guys he's had in the past. Different body types, different kind of guys that we bring to the table so he has to make that adjustment. But as far as his offense, his offense isn't going to change."
But the beauty and the beast of Turner's offense is that there are so many variables, even within one play, that his offense doesn't have to change with the players because the change is already built in. Eventually, that should be a good thing. In the short term, it means even a veteran receiver like Jennings has his head "spinning" from all the adjustments and possibilities.
Jennings said he will have to forget everything he has learned. Imagine what it does to a young player like Patterson, who had just one year of major college playing experience at Tennessee before entering the NFL in 2013.
"It's tough, I've been going through different offenses since high school, each year get a new coach, go to junior college, then Tennessee, then last year to this year," Patterson said. "It's been tough. I lean on the guys in that locker room. I lean on them a lot. They help me and expect big things from me and I expect big things from them."
Jennings doesn't expect it to take that long before the "complex" offense turns comfortable. With Turner on board, it just has to get to that point before the start of the season.
Tim Yotter is the publisher of Viking Update. Follow Viking Update on Twitter and discuss this topic on our message boards. To become a subscriber to the Viking Update web site or magazine, click here.
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Here's an update and a correction on the story about Delonte West supposedly not being allowed to tag along with his Dallas Mavericks teammates for today's celebration at the White House.
Despite West's comments to the Fort Worth Star-Telegram that he was "banned" from the celebration of last season's NBA champions, he actually wasn't.
Secret Service spokesman Ed Donovan said West could have taken part. West inferred in his remarks to the newspaper that he couldn't attend because of his weapons conviction in 2010.
West wasn't a member of the championship squad, and only joined the Mavericks this season.
Saturday night, West told the Star-Telegram that: "I'm banned from going to the White House, so I'm not going to make it. But I'm going home to D.C., I'm just not allowed to go to the White House. That's what happens when you make bad decisions in your life. You can't go to the White House."
In 2009 a traffic stop of West resulted in police finding three weapons in a guitar case he was carrying on his three-wheel motorcycle. The next year he pleaded guilty to weapons and traffic charges and was sentenced to unsupervised probation, counseling, electronic monitoring and 40 hours of community service.
West also went on a twitter rant about the supposed situation. Those rambling have since been deleted, but they still can be seen at BleacherReport.com.
Reid Cherner has been with USA TODAY since 1982 and written Game On! since March 2008.
He has covered everything from high schools to horse racing to the college and the pros. The only thing he likes more than his own voice is the sound of readers telling him when he's right and wrong.
Michael Hiestand has covered sports media and marketing for USA TODAY, tackling the sports biz ranging from what's behind mega-events such as the Olympics and Super Bowl to the sometimes-hidden numbers behind the sports world's bottom line.


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Winners at Titan Poker's jackpot sit 'n' go tournaments are also in the running for big jackpot prizes if they win enough consecutive tournaments in a similar manner to Christian Todte.
The Rio and Maui Sit 'N' Go Tournaments offer starting jackpots of $25,000 and $15,000 respectively and grow progressively each week if no player manages to win enough consecutive tournaments to claim the jackpot prize.


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In the News
- June 16, 2017Sport Management Alum Takes Home International Award
- May 19, 2017Olson Named Interim Dean
- April 7, 2017UCCS makes Best Online MBA Degrees list
- February 12, 2017College of Business Seminar Explores Cybersecurity Risks
College of Business undergraduate students will earn a Bachelors of Science degree in Business or a Bachelor of Innovation degree. There are 11 areas of emphasis where Business students can focus their area of study and graduate with a particular distinction, such as Finance, Accounting, or PGA Golf Management. For more on areas of emphasis, visit our Areas of Emphasis page.
Graduate students can earn a Masters of Business Administration, or MBA degree or a Master of Science in Accounting, or MSA degree. Again, there are specific areas of emphasis that MBA students can specialize in. For more information on the MBA and MSA degrees, visit our Masters Degree page.
Admission to the UCCS College of Business is competitive. Admitted undergraduate students generally have an ACT composite of 24 (22 Math, 24 English) or above, or an SAT score of 1080 (Verbal + Math) or above, and fall within the top 30% of their senior class. However, students with lower credentials can still be admitted. For more information on strengthening your admission candidacy, visit our Future Students Undergraduate Admission page.
For graduate admission questions, please contact our Graduate Programs Office.
Most undergraduate students at the UCCS College of Business who are Colorado residents will spend between $7,024 - $8,658 on tuition and fees per year (depending on the number of classes he/she takes). For students from states that participate in the Western Undergraduate Exchange program, this ranges from $12,676 - $15,274. For other non-resident students, this ranges from $18,436 - $18,565.
On-campus housing expense averages $10,200 per year, including meals.
For a more detailed breakdown of what your costs could be, visit our Costs & Financial Aid page.
For details about graduate student costs, please contact our Graduate Programs office.
College of Business students are positioned for success through internships and career placement, as well as real-world business skills that they can apply immediately in the workplace. Employers comment that UCCS College of Business graduates are ready to contribute to their organization right away due to their case-study based training and hands-on experience using the skills they learn in the classroom.
Our Career and Placement Office places hundreds of students into internships and full-time positions each year. Studies show that students who have gained experience in their field through internships are much more likely to secure a position upon graduation. For more information on internship and career placement, please visit our Career & Placement Office website.
Probably not. While managing paying for college and taking on debt is every individual student's responsibility, on average, UCCS graduates do better than most. Based on the most recent published data, UCCS students graduated with an average debt load of approximately $25,500, far below the national average of $35,000. UCCS helps students manage their debt by offering numerous student employment options, as well as generous financial aid awards.
Also, UCCS students manage their debt well, having an average default rate of only 2.8% compared to a national average of 12% (AY 2011-12). For more information on paying for college, please visit our Scholarships & Financial Aid website.


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