Access to emergency care services: a transversal ecological study about Brazilian emergency health care network.

OBJECTIVES: Studies of health geography are important in the planning and allocation of emergency health services. The geographical distribution of health facilities is an important factor in timely and quality access to emergency services; therefore, the present study analyzed the emergency health care network in Brazil, focusing the analysis at the roles of small hospitals (SHs). STUDY DESIGN: Cross-sectional ecological study. METHODS: Data were collected from 9429 hospitals of which 3524 were SHs and 5905 were high-complexity centers (HCCs). For analytical purposes, we considered four specialties when examining the proxies of emergency care capability: adult, pediatrics, neonatal, and obstetric. We analyzed the spatial distribution of hospitals, identifying municipalities that rely exclusively on SHs and the distance of these cities from HCCs. RESULTS: More than 14 and 30 million people were at least 120 km away from HCCs with an adult intensive care unit (ICU) and pediatric ICU, respectively. For neonatal care distribution, 12% of the population was more than 120 km away from a health facility with a neonatal ICU. The maternities situation is different from other specialties, where 81% of the total Brazilian population was within 1 h or less from such health facilities. CONCLUSION: Our results highlighted a polarization in distribution of Brazilian health care facilities. There is a concentration of hospitals in urban areas more developed and access gaps in rural areas and the Amazon region. Our results demonstrate that the distribution of emergency services in Brazil is not facilitating access to the population due to geographical barriers associated with great distances.

[Abundance and activity of microorganisms at the water-sediment interface and their effect on the carbon isotopic composition of suspended organic matter and sediments of the Kara Sea].

At ten stations of the meridian profile in the eastern Kara Sea from the Yenisei estuary through the shallow shelf and further through the St. Anna trough, total microbial numbers (TMN) determined by direct counting, total activity of the microbial community determined by dark CO2 assimilation (DCA), and the carbon isotopic composition of organic matter in suspension and upper sediment horizons (δ13C, per thousand) were investigated. Three horizons were studied in detail: (1) the near-bottom water layer (20-30 cm above the sediment); (2) the uppermost, strongly hydrated sediment horizon, further termed warp (5-10 mm); and (3) the upper sediment horizon (1-5 cm). Due to decrease in the amount of isotopically light carbon of terrigenous origin with increasing distance from the Yenisei estuary, the TMN and DCA values decreased, and the δ13C changed gradually from -29.7 to -23.9 per thousand. At most stations, a noticeable decrease in TMN and DCA values with depth was observed in the water column, while the carbon isotopic composition of suspended organic matter did not change significantly. Considerable changes of all parameters were detected in the interface zone: TMN and DCA increased in the sediments compared to their values in near-bottom water, while the 13C content increased significantly, with δ13C of organic matter in the sediments being at some stations 3.5- 4.0 per thousand higher than in the near-bottom water. Due to insufficient illumination in the near-bottom zone, newly formed isotopically heavy organic matter (δ13C(-) -20 per thousand) could not be formed by photosynthesis, active growth of chemoautotrophic microorganisms in this zone is suggested, which may use reduced sulfur, nitrogen, and carbon compounds diffusing from anaerobic sediments. High DCA values for the interface zone samples confirm this hypothesis. Moreover, neutrophilic sulfur-oxidizing bacteria were retrieved from the samples of this zone.

[Microbial processes of the carbon and sulfur cycles in the White Sea].

The present paper contains the results of our microbiological and biogeochemical investigations carried out during a series of expeditions to the White Sea in 2002-2006. The studies were conducted in the open part of the White Sea, as well as in the Onega, Dvina, and Kandalaksha bays. In August 2006, the photosynthetic productivity in the surface water layer was low (47-145 mg C m(-2) day(-1)). Quantitative characteristics of microbial numbers and activity of the the key microbial processes occurring in the water column of the White Sea were explored. Over the 5-year period of observations, the total number of bacterial cells in the surface layer of the water column varied from 50 to 600 thousand cells ml(-1). In August 2006, bacterioplankton production (BP) was estimated to be 0.26-3.3 microg C l(-1) day(-1); the P/B coefficient varied from 0.22 to 0.93. The suspended organic matter had a lighter isotope composition (from -28.0 to -30.5 per thousand) due to the predominance of terrigenous organic matter delivered by the Northern Dvina waters. The interseasonal and interannual variation coefficients for phytoplankton production and BP numbers are compared. The bacterioplankton community of the White Sea's deep water was found to be more stable than that of the surface layer. In the surface layer of bottom sediments, methane concentration was 0.2-5.2 microl dm(-3); the rate of bacterial sulfate reduction was 18-260 microg S dm(-3) day(-1); and the rates of methane production and oxidation were 24-123 and 6-13 nl CH4 dm(-3) day(-1) respectively. We demonstrated that the rates of microbial processes of the carbon and sulfur cycles occurring in the sediments of the White Sea basin were low.

[Microbial processes of the carbon and sulfur cycles in the Chukchi Sea].

The research performed in August 2004 within the framework of the Russian-American Long-term Census of the Arctic (RUSALCA) resulted in the first data concerning the rates of the key microbial processes in the water column and bottom sediments of the Bering strait and the Chukchi Sea. The total bacterial counts in the water column varied from 30 x 10(3) cells ml(-1) in the northern and eastern parts to 245 x 10(3) cells ml(-1) in the southern part. The methane content in the water column of the Chukchi sea varied from 8 nmol CH4 l(-1) in the eastern part of the sea to 31 nmol CH4 l(-1) in the northern part of the Herald Canyon. Active microbial processes occurred in the upper 0-3 cm of the bottom sediments; the methane formation rate varied from 0.25 to 16 nmol CH4 dm(-3) day(-1). The rates of methane oxidation varied from 1.61 to 14.7 nmol CH4 dm(-3) day(-1). The rates of sulfate reduction varied from 1.35 to 16.2 micromol SO4(2-) dm(-3) day(-1). The rate of methane formation in the sediments increased with depth, while sulfate reduction rates decreased (less than 1 micromol SO4(2-) dm(-3) day(-1)). These high concentrations of biogenic elements and high rates of microbial processes in the upper sediment layers suggest a specific type of trophic chain in the Chukchi Sea. The approximate calculated balance of methane emission from the water column into the atmosphere is from 5.4 to 57.3 micromol CH4 m(-2) day(-1).

[Microbiological processes in the Lost City vent field, mid-Atlantic ridge].

Microbiological and biogeochemical measurements showed that the intensities of CO2 assimilation, methane oxidation, and sulfate reduction in the Lost City vent field (30 degrees N) reach 3.8 microg C/(1 day), 0.06 microg C/(1 day), and 117 microg S/(1 day), respectively. On the surface of the carbonate structures occurring in this field, two varieties of bacterial mats were found. The first variety, which is specific to the Lost City alkaline vent field, represents jelly bacterial mats dominated by slime-producing bacteria of several morphotypes. This mat variety also contains chemolithotrophic and heterotrophic microorganisms, either microaerobic or anaerobic. The intensities of CO2 assimilation, methane oxidation, and sulfate reduction in this variety reach 747 microg C/(dm3 day), 0.02 microg C/(dm3 day), and 28,000 microg S/(dm3 day), respectively. Bacterial mats of the second variety are formed by nonpigmented filamentous sulfur bacteria, which are close morphologically to Thiothrix. The intensities of CO2 assimilation, methane oxidation, and sulfate reduction in the second mat variety reach 8.2 microg C/(dm3 day), 5.8 microg C/(dm3 day), and 17,000 microg S/(dm3 day), respectively. These data suggest the existence of subsurface microflora in the Lost City vent field.

[The biogeochemical cycle of methane in the coastal zone and littoral of the Kandalaksha Bay of the White Sea]. / Biogeokhimicheskii tsikl metana v pribrezhnoi zone i litorali Kandalakshskogo zaliva Belogo moria.

Microbiological and biogeochemical investigations of the processes of methane production (MP) and methane oxidation (MO) in the coastal waters and littoral of the Kandalaksha Bay of the White Sea were carried out. The studies were conducted in the coastal zones and in the water areas of the Kandalaksha Preserve, Moscow University White Sea Biological Station, and Zoological Institute (RAS) Biological Station in August, 1999, 2000, and 2001 and in March, 2001. The rate of CO2 assimilation in the shallow and littoral sediments was 35-27800 microg C/(dm3 day) in summer and 32.8-88.9 microg C/(dm3 day) in winter. The maximal rates of MP were observed in the littoral sediments in the zone of macrophyte decomposition, in local depressions, and in the estuary of a freshwater creak (up to 113 microl/(dm3 day)). The maximal level of MO was observed in the shallow estuarine sediments (up to 2450 microl/(dm3 day)). During the winter season, at the temperature of -0.5 to 0.5 degrees C, the MP rate in the littoral sediments was 0.02-0.3 microl/(dm3 day), while MO rate was 0.06-0.7 microl/(dm3 day). The isotopic data obtained indicate that the C(org) of the mats and of the upper sediment layers is enriched with the heavy 13C isotope by 1-4 per thousand as compared to the C(org) of the suspension, comprised on 33.5-34.3% of phytoplankton. A striking difference was found between the levels of methane emission by the typical littoral microlanscapes. In fine sediments, the average emission was 675 microl CH4/(m2 day), in the stormy discharge stretch sediments it was 1670 microl CH4/(m2 day), and under the stones and in silted pits, 1370 microl CH4/(m2 day). The calculation performed with consideration of the microlandscape areas with a high production allowed the CH4 production of 1 km2 of the littoral to be estimated as 192-300 1 CH4/(km2 day).

[Methane content in bottom sediments and water mass of the Black Sea]. / Soderzhanie metana v donnykh osadkakh i vodnoi tolshche Chernogo moria.

The methane content in bottom sediments and water column of the Black Sea was determined using various methods of desorption and analysis of gases and various methods of calculating their concentrations. The head-space method with the use of salting out and calculation by internal standard proved to be the most accurate procedure for the analysis of methane concentration in bottom sediments. The methane content in bottom sediments increased with the depth of sediment sampling. In the upper 50-70 cm of shelf sediments, two minimums of methane concentration were revealed; in deep-sea sediments, only one minimum was recorded (in the 20-50 cm horizons). In the water column, methane concentrations slowly grew from the surface to a depth of 150-200 m and abruptly increased to a depth of 700-1200 m, remaining virtually constant in underlying layers. In certain deep-sea regions, peaks of methane content in the 1000-1200 m horizons of the water column were revealed, which were most probably due to local influx of abyssal waters enriched with this gas.

[Intensities of microbial production and oxidation of methane in bottom sediments and water mass of the Black Sea]. / Intensivnosti mikrobnogo obrazovaniia i okisleniia metana v donnykh osadkakh i vodnoi tolshche Chernogo moria.

Intensities of biogeochemical (microbial) processes of methane production and methane oxidation were determined in bottom sediments and water column of the Black Sea. Aerobic bacterial oxidation of methane is confined to the upper 20-30 cm of Holocene bottom sediments of the shelf (0.7-259 ng C/(dm3 day)) and oxygenated waters (0.2-45 ng C/(dm3 day)). In reduced sediments of the deep-sea zone and in the hydrogen sulfide-containing water column, considerable intensities of anaerobic methane oxidation were recorded, comparable to or exceeding the intensities of methane oxidation in oxygenated layers. From one fourth to one half of the methane formed in bottom sediments was oxidized immediately therein. The major part of the remaining methane was oxidized in the water column, and a smaller portion arrived in the atmosphere.

[Microbial sulfate reduction in sediments of the coastal zone and littoral of the Kandalaksha bay of the White sea]. / Protsess mikrobnoi sul'fatreduktsii v osadkakh pribrezhnoi zony i litorali Kandalakshskogo zaliva Belogo moria.

Microbiological and biogeochemical investigations of the coastal zone and the littoral of the Kandalaksha Bay of the White Sea were carried out. The material for investigations was obtained in the series of expeditions of the Institute of Microbiology, Russian Academy of Sciences, in August 1999, 2000, 2001, and in March 2003. The studies were conducted on the littoral and in the water area of the Kandalaksha Preserve, the Moscow University Belomorsk Biological Station, and the Zoological Institute Biological Station, Russian Academy of Sciences, Sediment sampling on the littoral was carried out in the typical microlandscapes differing in the sediment properties and macrobenthos distribution. The maximal sulfate reduction rate (SRR) was shown for the shallow part of the Chemorechenskaya Bay (up to 2550 micrograms S/(dm3 day)) and in the Bab'ye More Bay (up to 3191 micrograms S/(dm3 day)). During the winter season, at a temperature of -0.5-0.5 degrees C, the SRR in the sediments of the Kartesh Bay was 7.9-13 micrograms S/(dm3 day). In the widest limits, the SRR values varied in the sediment cores sampled on the littoral. The minimal values (11 mu]g S/(dm3 day)) were obtained in the core samples on the silt-sandy littoral. The littoral finely dispersed sediments rich in organic matter were characterized by high SRR values (524-1413 micrograms S/(dm3 day)). The maximal SRR values were shown for the sediments present within the stretch of decomposing macrophytes, in local pits at the lower littoral waterline, and in the mouth of a freshwater stream (51-159 mg S/(dm3 day)). A sharp difference in the level of H2S production in the type microlandscapes was shown. The average hydrogen sulfide production in finely dispersed sediments constituted 125 mg S/(m2 day); in stormy discharge deposits, 1950 mg S/(m2 day); in depressions under stones and in silted pits, 4300 mg S/(m2 day). A calculation made with regard to the area of microlandscapes with increased productivity shows that the daily H2S production per 1 km2 of the littoral (August) is 60.8 to 202 kg S/(km2 day), while the organic carbon consumption for sulfate reduction per 1 km2 of the littoral is 46 to 152 kg C(org)/(km2 day).

Sources of disseminated Mycobacterium avium infection in AIDS.

OBJECTIVES: To identify the sources of disseminated Mycobacterium avium complex (MAC) infection in AIDS. METHODS: HIV positive subjects with CD4 counts <100/mm(3) in Atlanta, Boston, New Hampshire and Finland were entered in a prospective cohort study. Subjects were interviewed about potential MAC exposures, had phlebotomy performed for determination of antibody to mycobacterial lipoarabinomannin and for culture. Patient-directed water samples were collected from places of residence, work and recreation. Patients were followed for the development of disseminated MAC. Univariate and multivariate risk factors for MAC were analyzed. RESULTS: Disseminated MAC was identified in 31 (9%) subjects. Significant risks in univariate analysis included prior Pneumocystis carinii pneumonia (PCP) (hazard ratio 1.821), consumption of spring water (4.909), consumption of raw seafood (34.3), gastrointestinal endoscopy (2.894), and showering outside the home (0.388). PCP, showering and endoscopy remained significant in a Cox proportional hazards model. There was no association between M. avium colonization of home water and risk of MAC. In patients with CD4<25, median OD antibody levels to lipoarabinomannin at baseline were 0.054 among patients who did not develop MAC and 0.021 among patients who did develop MAC (P=0.077). CONCLUSIONS: MAC infection results from diverse and likely undetectable environmental and nosocomial exposures. Mycobacterial infection before HIV infection may confer protection against disseminated MAC in advanced AIDS.

[Geochemical characteristics of the carbonate constructions formed during microbial oxidation of methane under anaerobic conditions]. / Geokhimicheskie osobennosti karbonatnykh postroek, obrazuiushchikhsia pri mikrobnom okislenii metana v anaérobnykh usloviiakh.

The aragonite constructions of the Black Sea are formed in a stable anaerobic zone and are a perfect object to study the natural mechanism of anaerobic methane oxidation. The most probable pathway of methane oxidation is its methanogen-mediated reaction with bicarbonates, dissolved in seawater, with the formation of water and acetate, which is then consumed by other components of the anaerobic community. Comparison of the delta 13C values of carbonate minerals and organic matter once more demonstrated that the formation of the organic matter of biomass is accompanied by intense fractionation of carbon isotopes, as a result of which the total organic matter of biomass acquires an extremely light isotopic composition, characterized by delta 13C values as low as -83.8@1000.

Skin test reactions to Mycobacterium tuberculosis purified protein derivative and Mycobacterium avium sensitin among health care workers and medical students in the United States.

SETTING: Health care workers and medical students in the United States subject to annual tuberculin skin testing. OBJECTIVE: To use skin testing with Mycobacterium avium sensitin (MAS) to determine contemporary rates of infection with non-tuberculous mycobacteria (NTM) and their effect on reactions to M. tuberculosis purified protein derivative (PPD). DESIGN: Dual skin testing was performed with PPD and MAS on 784 health care workers and medical students in the northern and southern US. MAS reactions that were > or = 5 mm and also > or = 3 mm larger than the PPD reaction were defined as MAS dominant and due to NTM. RESULTS: MAS reactions were > or = 5 mm in 40% and > or = 15 mm in 18% of subjects; 95% were MAS dominant. MAS dominant reactions were more common in the south than the north (P < 0.001). PPD reactions were > or = 15 mm in 3% of subjects. PPD reactions > or = 15 mm were more common among males, foreign born subjects and subjects with BCG immunization (all P < 0.001). MAS dominant reactions were found in 82% of subjects with 5-9 mm PPD reactions and 50% with 10-14 mm PPD reactions; these reactions were more common among whites (P = 0.046), US-born (P = 0.038) and subjects without BCG immunization (P = 0.004). CONCLUSIONS: Infections with NTM are responsible for the majority of 5-14 mm PPD reactions among US-born health care workers and medical students subject to annual tuberculin testing.

[Microbial processes of carbon and sulfur cycles in lake Mogil'noe]. / Mikrobnye protsessy tsikla ugleroda i sery v ozere Mogil'nom.

In the beginning of summer 1999, complex microbiological and biogeochemical investigations of meromictic Lake Mogil'noe (Kil'din Island, Barents Sea) were carried out. The analysis of the results shows clearly pronounced vertical zonality of the microbial processes occurring in the water column of the lake. To a depth of 8 m, the total number and activity of microorganisms was limited by the relatively low content of organic matter (OM). In the upper part of the hydrogen-sulfide zone of the lake (beginning at a depth of 8.25 m), the content of particulate OM and the microbial number sharply increased. In this zone, the daily production of OM during anaerobic photosynthesis at the expense of massive development of colored sulfur bacteria reached 620 mg C/m2, which was twofold greater than the daily production of phytoplankton photosynthesis and led to a considerable change in the isotopic composition (delta 13 C) of the particulate OM. In the same intermediate layer, the highest rates of sulfate reduction were recorded, and fractionation of stable sulfur isotopes occurred. Below 10 m was the third hydrochemical zone, characterized by maximum concentrations of H2S and CH4 and by a relatively high rate of autotrophic methanogenesis. The comparison of the results obtained with the results of investigations of previous years, performed in the end of summer, shows a decrease in the intensity of all microbial processes inspected. An exception was anoxygenic photosynthesis, which can utilize not only the de novo formed H2S but also the H2S accumulated in the lake during the winter period.

[Microbiological processes at the interface of aerobic and anaerobic waters in the deep-water zone of the Black Sea]. / Mikrobiologicheskie protsessy na granitse aérobnykh i anaérobnykh vod v glubokovodnoi zone chernogo moria.

Chemical and key microbiological processes (assimilation of carbon dioxide, oxidation and formation of methane, and sulfate reduction) occurring at the boundary between the aerobic-anaerobic interface in the deep-water zone of the Black Sea were investigated. Measurements were taken at depths from 90 to 300 m at intervals of 5-10 m. The integral rate of the dark assimilation of carbon dioxide varied from 120 to 207 mg C/(m2 day) with a maximum at the boundary of cyclonic currents. The organic matter (OM) formed from methane comprised less than 5% of the OM formed from carbon dioxide. A comparison between the rates of methane oxidation and methane production suggests that methane that is oxidized at depths from 100 to 300 m was formed in deeper water horizons. The maximum rate of sulfate reduction (1230 mg S/(m2 day)) was observed in the western halistatic region, and the minimum rate (490 mg S/(m2 day)), in the eastern halistatic region. The average rate of hydrogen sulfide production measured at three deep-sea stations amounted to 755 mg S/(m2 day), or 276 g S/(m2 year).

[Effect of microorganisms and seasonal factors on the isotope composition of organic carbon from Black Sea suspensions]. / Vliianie mikroorganizmov i sezonnykh faktorov na izotopnyi sostav organicheskogo ugleroda vzvesi chernogo moria.

The isotopic composition of particulate organic carbon (POC) from the Black Sea deep-water zone was studied during a Russian-Swiss expedition in May 1998. POC from the upper part of the hydrogen sulfide zone (the C-layer) was found to be considerably enriched with the 12C isotope, as compared to the POC of the oxycline and anaerobic zone. In the C-layer waters, the concurrent presence of dissolved oxygen and hydrogen sulfide and an increased rate of dark CO2 fixation were recorded, suggesting that the change in the POC isotopic composition occurs at the expense of newly formed isotopically light organic matter of the biomass of autotrophic bacteria involved in the sulfur cycle. In the anaerobic waters below the C-layer, the organic matter of the biomass of autotrophs is consumed by the community of heterotrophic microorganisms; this results in weighting of the POC isotopic composition. Analysis of the data obtained and data available in the literature allows an inference to be made about the considerable seasonable variability of the POC delta 13C value, which depends on the ratio of terrigenic and planktonogenic components in the particulate organic matter.

Safety and immunogenicity of a five-dose series of inactivated Mycobacterium vaccae vaccination for the prevention of HIV-associated tuberculosis.

Five doses of inactivated Mycobacterium vaccae vaccine were administered intradermally to 22 human immunodeficiency virus (HIV)-infected patients (11 bacille Calmette-Guérin [BCG]-positive and 11 BCG-negative) in Zambia whose CD4 lymphocyte counts were >/=200 cells/mm(3). HIV viral load and lymphocyte proliferation responses were compared for vaccine recipients and 22 HIV-infected control patients (11 BCG-positive and 11 BCG-negative). Immunization was safe and well tolerated in all patients, and induration at the vaccine site decreased from dose 1 to dose 5. A transient decrease in HIV viral load was observed in BCG-positive vaccine recipients after dose 3 but not after subsequent doses. Median lymphocyte stimulation indices to M. vaccae were 6.0 in vaccine recipients and 2.3 in control patients (P<.001). Stimulation indices were >/=3.0 in 19 vaccine recipients (86%) and 7 control patients (32%; P=.001). A 5-dose series of vaccination with inactivated M. vaccae is safe in HIV-infected patients and induces lymphocyte proliferation responses to the vaccine antigen. M. vaccae vaccine is a candidate for the prevention of tuberculosis in HIV infection.