Small hospitals matter: insights from the emergence and spread of vancomycin-resistant enterococci in 2 public hospitals in inner Brazil

Although vancomycin-resistant enterococci (VRE) are reported in Brazil since 1996, data on their impact over settings of different complexity are scarce. We performed a study aimed at identifying determinants ofVRE emergence and spread in a public hospital consortium (comprising 2 hospitals, with 318 and 57 beds) in inner Brazil. Molecular typing and case-control studies (addressing predictors of acquisition or clonality) were performed. Among 122 authocthonous isolates, 106 were Enterococcus faecium (22 clones), and 16, Enterococcus faecalis (5 clones). Incidence was greater in the small-sized hospital, and a previous admission to this hospital was associated with greater risk of VRE colonization or infection during admission to the larger one. Overall risk factors included comorbidities, procedures, and antimicrobials (piperacillin-tazobactam, cefepime, and imipenem). Risk factors varied among different hospitals, species, and clones. Our findings demonstrate that VRE can spread within low-complexity facilities and from these to larger hospitals. (C) 2015 Elsevier Inc. All rights reserved.

The ant fauna of hospitals: advancements in public health and research priorities in Brazil

Ants inhabit several types of natural and urban habitats, where they successfully nest. In urban environments, the hospitals should be considered priority for studies, as ants pose risks to human health due to their pathogen carrying potential. We aimed at surveying the literature about studies on ants in hospital settings in Brazil in the past 20 years. We found 40 papers in 22 journals, the first one published in 1993. Among them, 26 papers assessed pathogenic microorganisms on ants. We recorded 59 ant species, being Tapinoma melanocephalum the most common. The Minas Gerais and Sao Paulo states had the largest number of published papers. Mato Grosso do Sul and Rio Grande do Sul showed the highest number of species. Exotic ant species were recorded in all states, except Goias. Considering the potential to carry microorganisms and the importance of thorough studies on the ecology of ant species, our results can support and guide further research in Brazil. (C) 2015 Sociedade Brasileira de Entomologia. Published by Elsevier Editora Ltda. All rights reserved.

The Critical Reception of Beethoven’s Compositions by His German Contemporaries, volume 2

The volumes in The Critical Reception of Beethoven's Compositions by His German Contemporaries bring to light contemporary perceptions of Beethoven's music, including matters such as audience, setting, facilities, orchestra, instruments, and performers as well as the relationship of Beethoven's music to theoretical and critical ideas of the eighteenth and nineteenth centuries. These documents, most of which appear in English for the first time, have been compiled from German-language periodicals published between 1783 and 1830. They present a wide spectrum of insights into the perceptions that Beethoven's contemporaries had of his monumental music. This is the second in a projected four-volume series. It begins with Opus 55, the Eroica, and ends with Opus 72, Fidelio.

Nebraska Panhandle Connects with German Institute on Agri Benchmark Project

In the Spring of 2009, the University of Nebraska Panhandle Research and Extension Center was contacted by a representative from the Institute of Farm Economics at the Johann Heinrich von Thunen Institute (vTI) in Braunschweig, Germany. In the initial meeting, a partnership was arranged to provide Western Nebraska irrigated economic data for the Agri Benchmark project operated by vTI, with the University of Nebraska receiving access to the worldwide data set that exists within the project. This relationship has grown over the past 18 months to include a number of other opportunities.

The History of the German-Russian Colony in Lincoln

Standing at the corner of Tenth and O streets in the city of Lincoln, Nebraska, any week-day morning between 7:30 and 8 o'clock, you may see pass by you from ten to twenty women with little black woolen shawls on their heads. Ask any citizen who they are, and ninety-nine times in one hundred he will tell you they are "Russians" who live down on the bottoms, that they are going out into the offices and homes to wash and scrub and clean house, and that their husbands are street laborers or work for the railroad. He may then grow confidential and tell you that he "has no use for these people", that "they are only half human", and that he "would just as soon see the Chinese come here as those people". As a matter of fact the greater part of his information is incorrect, partly through race prejudice but chiefly through ignorance of their history. These people, of whom there are about 4,000 in the city (Including "beet fielders"), are Germans, not Russians: they are Teutons, not Slavs; they are Lutheran and Reformed, not Greek Catholics. To be sure they and their ancestors lived in Russia for over one hundred years and they came here directly from the realm of the Czar whoso bona fide citizens they were—but they never spoke the Russian language, never embraced the Greek religion, never intermarried with the Russians, and many of their children never saw a Russian until they left their native village for the new home in America. They despise being called "Russians" just as an Italian resents "Dago"; a Jew, "Sheeny"; and a German, "Dutchman". Ask them where they came from and most of the children and not a few of the grown people will say, "Germany". If you pursue your questioning as to what part of Germany, they will tell you "Saratov" or "Samara" - two governments in the eastern part of Russia on the lower course of the Volga river. The misconceptions concerning the desirability of these German-Russians as citizens arise from their unprogressiveness as compared with those Germans who come to us directly from the mother country. During their century's sojourn in Russia they have been out of the main current of civilization, a mere eddy in the stream of progress. They present a concrete example of arrested development, The characteristics which differentiate them from other Germans are not due to an inherent lack of capacity but to different environment. Notwithstanding this, the German- Russians have some admirable qualities. They bring us large stores of physical energy and an almost unlimited capacity for work. The majority of them are literate although the amount of their education is limited. They are thrifty and independent, almost never applying for public aid. They are law abiding, their chief offenses being those which are traceable to their communal life in Russia. They are extremely religious, all their social as well as spiritual life being bound up in the church which they support right royally. To be sure, the saloon gets their vote (the prohibition vote among them is increasing); but "was not the first miracle that Christ performed the turning of water into wine? If they would shut up the shows (theaters), they wouldn't need to shut up the saloons". The object of this paper is to give the historical setting in which the German-Russians have lived as one means to a better understanding and appreciation of them by our own citizens.

IMMIGRATION, THE AMERICAN WEST, AND THE TWENTIETH CENTURY: GERMAN FROM RUSSIA, OMAHA INDIAN, AND VIETNAMESE-URBAN VILLAGERS IN LINCOLN, NEBRASKA

The North American West is a culturally and geographically diverse region that has long been a beacon for successive waves of human immigration and migration. A case in point, the population of Lincoln, Nebraska -- a capital city on the eastern cusp of the Great Plains -- was augmented during the twentieth century by significant influxes of Germans from Russia, Omaha Indians, and Vietnamese. Arriving in clusters beginning in 1876, 1941, and 1975 respectively, these newcomers were generally set in motion by dismal economic, social, or political situations in their sending nations. Seeking better lives, they entered a mainstream milieu dominated by native-born Americans -- most part of a lateral migration from Iowa, Illinois, and Pennsylvania -- who only established their local community in 1867. While this mainstream welcomed their labor, it often eschewed the behaviors and cultural practices ethnic peoples brought with them. Aware but not overly concerned about these prejudices, all three groups constructed or organized distinct urban villages. The physical forms of these enclaves ranged from homogeneous neighborhoods to tight assemblies of relatives, but each suited a shared preference for living among kinspeople. These urban villages also served as stable anchors for unique peoples who were intent on maintaining aspects of their imported cultural identities. Never willing to assimilate to mainstream norms, urban villagers began adapting to their new milieus. While ethnic identity constructions in Lincoln proved remarkably enduring, they were also amazingly flexible. In fact, each subject group constantly negotiated their identities in response to interactions among particular, cosmopolitan, and transnational forces. Particularism refers largely to the beliefs, behaviors, and organizational patterns urban villagers imported from their old milieus. Cosmopolitan influences emanated from outside the ethnic groups and were dictated largely but not exclusively by the mainstream. Transnationalism is best defined as persistent, intense contact across international boundaries. These influences were important as the particularism of dispersed peoples was often reinforced by contact with sending cultures. Adviser: John. R. Wunder

Epidemiological and clinical characteristics of nosocomial candidiasis in university hospitals in Cuiaba - Mato Grosso, Brazil

Background: Fungal infections are emerging as an important cause of human disease, especially among hospitalized patients with serious underlying disease and several risk factors. Aims: To evaluate epidemiological and clinical characteristics of patients with nosocomial candidiasis in university hospitals in Cuiaba - MT, Brazil. Methods: A descriptive study of 91 patients admitted to university hospitals in Cuiaba - MT, with clinical and laboratory diagnosis of nosocomial candidiasis, over a 20-month period. Results: A rate for nosocomial infections by Candida spp. of 5 per 1000 admissions, proportional mortality of 14.4% and lethality of 53.8% were determined. The patient age ranged from 29 days to 82 years-old, among which, 74.7% were adults and 25.3% children. The intensive care units contributed with the highest number of cases of infection by Candida spp. (69.2%). The most important underlying disease was gastrointestinal tract disease (11%). Prematurity and low birth weight were the most important risk factors among newborns. The use of antibiotics, invasive procedures, H-2 blockers, multiple blood transfusions and stay length of >= 21 days were the most frequent risk factors among adults. Candida albicans was the most common species in all cases. Conclusions: In this study, C. albicans was the most frequently detected species in candidiasis and risk factors increased the susceptibility of hospitalized patients to acquiring a nosocomial infection by Candida spp. (C) 2011 Revista Iberoamericana de Micologia. Published by Elsevier Espana, S.L. All rights reserved.

Gauging food and nutritional care quality in hospitals

Background: Food and nutritional care quality must be assessed and scored, so as to improve health institution efficacy. This study aimed to detect and compare actions related to food and nutritional care quality in public and private hospitals. Methods: Investigation of the Hospital Food and Nutrition Service (HFNS) of 37 hospitals by means of structured interviews assessing two quality control corpora, namely nutritional care quality (NCQ) and hospital food service quality (FSQ). HFNS was also evaluated with respect to human resources per hospital bed and per produced meal. Results: Comparison between public and private institutions revealed that there was a statistically significant difference between the number of hospital beds per HFNS staff member (p = 0.02) and per dietitian (p < 0.01). The mean compliance with NCQ criteria in public and private institutions was 51.8% and 41.6%, respectively. The percentage of public and private health institutions in conformity with FSQ criteria was 42.4% and 49.1%, respectively. Most of the actions comprising each corpus, NCQ and FSQ, varied considerably between the two types of institution. NCQ was positively influenced by hospital type (general) and presence of a clinical dietitian. FSQ was affected by institution size: large and medium-sized hospitals were significantly better than small ones. Conclusions: Food and nutritional care in hospital is still incipient, and actions concerning both nutritional care and food service take place on an irregular basis. It is clear that the design of food and nutritional care in hospital indicators is mandatory, and that guidelines for the development of actions as well as qualification and assessment of nutritional care are urgent.

Spiritist Psychiatric Hospitals in Brazil: Integration of Conventional Psychiatric Treatment and Spiritual Complementary Therapy

In Brazil, during the XX century, dozens of Spiritist psychiatric hospitals emerged seeking to integrate conventional medical treatment with complementary spiritual therapy. This combined inpatient treatment is largely found in Brazil, where many psychiatric hospitals stem from the Spiritist movement. The present report describes the use of these spiritual practices, their operating structure, health professionals involved, modalities of care, and institutional difficulties in integrating spiritual practices with conventional treatment in six leading Brazilian Spiritist psychiatric hospitals. These hospitals combine conventional psychiatric treatment with voluntary-based spiritual approaches such as laying on of hands ("fluidotherapy"), lectures regarding spiritual and ethical issues, intercessory prayer, spirit release therapy ("disobsession") and "fraternal dialogue". The non-indoctrination and optional nature of these spiritual complementary therapies seem to increase acceptance among patients and their family members. In conclusion, the Spiritist psychiatric hospitals in Brazil have, for more than half a century, provided an integrative approach in the treatment of psychiatric disorders, associating conventional and spiritual treatments, more specifically Spiritist therapy. The lack of standardized treatment protocols and scientific studies remain a barrier to assessing the impact of this integrative approach on patients' mental health, quality of life, adherence, and perceived quality of treatment.

Genetic features and molecular epidemiology of Enterococcus faecium isolated in two university hospitals in Brazil

The global emergence of vancomycin-resistant Enterococcus faecium (VREfm) has been characterized by a clonal spread of strains belonging to clonal complex 17 (CC17). Genetic features and clonal relationships of 53 VREfm isolated from patients in 2 hospitals in Ribeirao Preto, Sao Paulo, Brazil, during 2005-2010 were determined as a contribution to the Brazilian evolutionary history of these nosocomial pathogens. All isolates were daptomycin susceptible, vancomycin-resistant, and had the vanA gene. The predominant virulence genes were acm and esp. Only 5 VREfm isolated in 2005-2006 had intact Tn1546, while 81% showed Tn1546 with deleted left extremity and insertion of IS1251 between the vanS and vanH genes. Multilocus sequence typing analysis permitted the identification of 9 different sequence types (STs), with 5 being new ones (656, 657, 658, 659, and 660). Predominant STs were ST412 and ST478, all belonging to CC17, except ST658. This is the first report of the ST78 in Brazil. (c) 2012 Elsevier Inc. All rights reserved.

Determination of decimal reduction time (D value) of chemical agents used in hospitals for disinfection purposes

Abstract Background Prior to the selection of disinfectants for low, intermediate and high (sterilizing) levels, the decimal reduction time, D-value, for the most common and persistent bacteria identified at a health care facility should be determined. Methods The D-value was determined by inoculating 100 mL of disinfecting solution with 1 mL of a bacterial suspension (104 – 105 CFU/mL for vegetative and spore forms). At regular intervals, 1 mL aliquots of this mixture were transferred to 8 mL of growth media containing a neutralizing agent, and incubated at optimal conditions for the microorganism. Results The highest D-values for various bacteria were determined for the following solutions: (i) 0.1% sodium dichloroisocyanurate (pH 7.0) – E. coli and A. calcoaceticus (D = 5.9 min); (ii) sodium hypochlorite (pH 7.0) at 0.025% for B. stearothermophilus (D = 24 min), E. coli and E. cloacae (D = 7.5 min); at 0.05% for B. stearothermophilus (D = 9.4 min) and E. coli (D = 6.1 min) and 0.1% for B. stearothermophilus (D = 3.5 min) and B. subtilis (D = 3.2 min); (iii) 2.0% glutaraldehyde (pH 7.4) – B. stearothermophilus, B. subtilis (D = 25 min) and E. coli (D = 7.1 min); (iv) 0.5% formaldehyde (pH 6.5) – B. subtilis (D = 11.8 min), B. stearothermophilus (D = 10.9 min) and A. calcoaceticus (D = 5.2 min); (v) 2.0% chlorhexidine (pH 6.2) – B. stearothermophilus (D = 9.1 min), and at 0.4% for E. cloacae (D = 8.3 min); (vi) 1.0% Minncare® (peracetic acid and hydrogen peroxide, pH 2.3) – B. stearothermophilus (D = 9.1 min) and E. coli (D = 6.7 min). Conclusions The suspension studies were an indication of the disinfectant efficacy on a surface. The data in this study reflect the formulations used and may vary from product to product. The expected effectiveness from the studied formulations showed that the tested agents can be recommended for surface disinfection as stated in present guidelines and emphasizes the importance and need to develop routine and novel programs to evaluate product utility.

Active tectonics in the NW-German Basin: Evidence from correlations between the modern landscape and deep geological structures (Lower Saxony, river Hunte)

KurzfassungIm Einzugsgebiet der Hunte (NW-Deutsches Becken, Niedersachsen) wurde untersucht, ob die Landschaftsgenese durch tektonische Bewegungen der Oberkruste beeinflußt ist. Krustenbewegungen führten im Bereich einer Hauptschollengrenze zu einer Hebung der weichselzeitlichen Niederterrasse (durchschnittliche Hebungssrate von ~0,5 mm/a über die letzten 12000 Jahre). Tektonischer Einfluß auf die heutige Landoberfläche ist über einem permischen Salzkissen zu verzeichnen, wo sich das Gefälle der holozänen Aue umkehrt. Krustenbewegungen haben mit großer Wahrscheinlichkeit Vorzugsrichtungen verursacht, die an der Tertiärbasis und in der heutigen Landschaft nachweisbar sind (0-5° und 90-95°). Das Abfließen der Hunte nach Norden scheint durch eine aktive, nordwärts gerichtete Kippung des NW-Deutschen Beckens verursacht zu sein. Hohe lineare Korrelationskoeffizienten zwischen Tiefenlage der Tertiärbasis und Höhenlage der heutigen Landoberfläche weisen auf eine aktive Kippung des Beckens hin. Beckensubsidenz hat möglicherweise die Akkumulation der weichselzeitlichen Niederterrasse gesteuert, da eine Übereinstimmung zwischen rezenter Beckensubsidenz und durchschnittlicher Sedimentationsrate des Niederterrassenkörpers besteht. Untersuchungen an einer geschlossenen Hohlform deuten auf eine aktive Sackungsstruktur hin, da sich Anomalien des geologischen Untergrundes mit der topographischen Lage der Struktur decken.

Langzeitergebnisse der laparoskopischen Leistenhernienreparation (TAPP) der Klinik für Allgemein- und Visceralchirurgie des St. Vincenz und Elisabeth Hospitals Mainz

Das Vorliegen einer Leistenhernie ist Ausdruck einer Insuffizienz der bindegewebi-gen Stabilisierungsmechanismen der Leistenkanalrückwand. Deshalb können auch nur diejenigen Operationsmethoden, welche die Hinterwand des Leistenkanals stabil verstärken, zu einem dauerhaftem Erfolg führen. Die sogenannten konventionellen Methoden nach Bassini, Mcvay und Shouldice versuchen, durch einen anterioren inguinalen Zugang die Hinterwand des Leisten-kanals mit autologem ortsständigem Gewebe zu verstärken. Dabei wird jedoch durch die Verwendung lokaler Strukturen die erzielte Stabilitätserhöhung mit einem allgemeinen Anstieg der Gewebsspannung in der Leistenregion erkauft. Das Konzept der spannungsfreien Operationsmethoden versucht, auf eine Verstär-kung der Hinterwand des Leistenkanals durch die Raffung lokaler Strukturen zu verzichten und damit verbundene postoperative Schmerzen und spannungsbeding-te Gewebsnekrosen zu minimieren. Die spannungsfreie Verstärkung der Hinter-wand des Leistenkanals wird dabei durch Verwendung synthetischer Fremdmateri-alien erreicht. Diese können sowohl in einem konventionellen anterioren Zugang (z.B. nach Lichtenstein, Rutkow) als auch minimalinvasiv endoskopisch (z.B. TAPP, TEPP) eingebracht werden. Seit Anfang der 1990er Jahre hat die laparoskopische Chirurgie sprunghaft zuge-nommen (Schumpelick et al. 1996), denn durch minimale Invasivität, modernes Instrumentarium und computergestützte Technologie erfüllt sie alle Forderungen der modernen Chirurgie nach Praktikabilität, Gewebeschonung, geringer Schmerz-haftigkeit und schneller Rehabilitation (Mayer et al. 1997). Dabei kam es zu einer vielfältigen Weiterentwicklung der endoskopischen Technik zur Leistenhernioplastik: standen zunächst noch endoskopische Naht- und Klam-mertechniken im Fokus (Ger et al. 1990, Meyer 1991), lag bald schon der Schwer-punkt auf einer spannungsfreien Reparation mit Hilfe alloplastischer Materialien (Arregui et al. 1992, Corbitt 1991, Corbitt et al. 1993), die sowohl als zweidimensi-onale Netze als auch in dreidimensionaler Ausprägung (Röllchen, Schirmchen, Plugs) zum Einsatz kamen (Shultz et al. 1990, Schleef et al. 1992, Amid et al. 19994, Dudai 1995). In der Folgezeit entwickelte sich noch eine Diskussion um den endoskopischen Zugangsweg, als nach zunächst rein laparoskopischem Vorgehen (TAPP) auch ein total extraperitonealer Zugang im präperitonealen Raum (TEPP) beschrieben und mit entsprechend verlässlichem Instrumentarium verfügbar wurde. Allgemein anerkannt sind heute bei den minimal invasiven Verfahren sowohl TAPP als auch TEPP und die Verwendung alloplastischer Netze oder dreidimensionaler Plug-Netz-Kombinationen zur dorsalen Verstärkung der Fascia transversalis (Bitt-ner et al. 1995, Horeyseck et al. 1999). Reine Naht- oder Cliptechniken werden wegen schlechter Ergebnisse nicht mehr empfohlen. Zugleich mit der Laparoskopie hat die offene Netzhernioplastik nach Lichtenstein ihre Aktualität jedoch nicht verloren (Horeyseck et al. 1999), im Gegenteil: durch zunehmende Verlagerung der Leistenhernienchirurgie in den ambulanten Bereich nimmt sie wieder an Umfang deutlich zu.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1(st) revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the "German Instrument for Methodological Guideline Appraisal" of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.