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Between 1 September 2005 and 30 June 2006, 19 medical centers collected 4,180 isolates recovered from clinical specimens from patients in intensive care units (ICUs) in Canada. The 4,180 isolates were collected from 2,292 respiratory specimens (54.8%), 738 blood specimens (17.7%), 581 wound/tissue specimens (13.9%), and 569 urinary specimens (13.6%). The 10 most common organisms isolated from 79.5% of all clinical specimens were methicillin-susceptible Staphylococcus aureus (MSSA) (16.4%), Escherichia coli (12.8%), Pseudomonas aeruginosa (10.0%), Haemophilus influenzae (7.9%), coagulase-negative staphylococci/Staphylococcus epidermidis (6.5%), Enterococcus spp. (6.1%), Streptococcus pneumoniae (5.8%), Klebsiella pneumoniae (5.8%), methicillin-resistant Staphylococcus aureus (MRSA) (4.7%), and Enterobacter cloacae (3.9%). MRSA made up 22.3% (197/884) of all S. aureus isolates (90.9% of MRSA were health care-associated MRSA, and 9.1% were community-associated MRSA), while vancomycin-resistant enterococci (VRE) made up 6.7% (11/255) of all enterococcal isolates (88.2% of VRE had the vanA genotype). Extended-spectrum β-lactamase (ESBL)-producing E. coli and K. pneumoniae occurred in 3.5% (19/536) and 1.8% (4/224) of isolates, respectively. All 19 ESBL-producing E. coli isolates were PCR positive for CTX-M, with blaCTX-M-15 occurring in 74% (14/19) of isolates. For MRSA, no resistance against daptomycin, linezolid, tigecycline, and vancomycin was observed, while the resistance rates to other agents were as follows: clarithromycin, 89.9%; clindamycin, 76.1%; fluoroquinolones, 90.1 to 91.8%; and trimethoprim-sulfamethoxazole, 11.7%. For E. coli, no resistance to amikacin, meropenem, and tigecycline was observed, while resistance rates to other agents were as follows: cefazolin, 20.1%; cefepime, 0.7%; ceftriaxone, 3.7%; gentamicin, 3.0%; fluoroquinolones, 21.1%; piperacillin-tazobactam, 1.9%; and trimethoprim-sulfamethoxazole, 24.8%. Resistance rates for P. aeruginosa were as follows: amikacin, 2.6%; cefepime, 10.2%; gentamicin, 15.2%; fluoroquinolones, 23.8 to 25.5%; meropenem, 13.6%; and piperacillin-tazobactam, 9.3%. A multidrug-resistant (MDR) phenotype (resistance to three or more of the following drugs: cefepime, piperacillin-tazobactam, meropenem, amikacin or gentamicin, and ciprofloxacin) occurred frequently in P. aeruginosa (12.6%) but uncommonly in E. coli (0.2%), E. cloacae (0.6%), or K. pneumoniae (0%). In conclusion, S. aureus (MSSA and MRSA), E. coli, P. aeruginosa, H. influenzae, Enterococcus spp., S. pneumoniae, and K. pneumoniae are the most common isolates recovered from clinical specimens in Canadian ICUs. A MDR phenotype is common for P. aeruginosa isolates in Canadian ICUs.
The global escalation in both community- and hospital-acquired antimicrobial-resistant bacteria is threatening the ability to effectively treat patients, underscoring the need for continued surveillance, more appropriate antimicrobial prescribing, prudent infection control, and new treatment alternatives (1, 10, 11, 14, 18, 27). Antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) (community-associated [CA-MRSA] and health care-associated [HA-MRSA]), vancomycin-resistant Enterococcus species (VRE), penicillin-resistant Streptococcus pneumoniae, extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella species, and fluoroquinolone-resistant and carbapenem-resistant members of the family Enterobacteriaceae and Pseudomonas aeruginosa are increasing in prevalence in all regions of Canada, in the United States, and globally (3-5, 8, 9, 13, 17-20, 22, 24, 28, 29, 31, 33). Available therapeutic options for antibiotic-resistant organisms are severely limited, as these organisms frequently display a multidrug-resistant (MDR) phenotype (18, 27, 31).
The purpose of this study was to assess the prevalence of pathogens, including the resistance genotypes of MRSA, VRE, and ESBL-producing bacteria, causing infections in patients in Canada intensive care units (ICUs), as well as their antimicrobial resistance patterns. The present report is the first national, prospective surveillance study assessing antimicrobial resistance in patients in ICUs in Canada.
(This paper was presented in part at the 46th Interscience Conference on Antimicrobial Agents and Chemotherapy in 2006 in San Francisco, CA.)
Bacterial isolates.Study isolates were obtained as part of the Canadian National Intensive Care Unit (CAN-ICU) study. The CAN-ICU study included 19 medical centers from all regions of Canada with active ICUs (see Acknowledgments and the website www.can-r.ca ). From September 2005 to June 2006, inclusive, each center collected a maximum of 300 consecutive isolates recovered from clinical specimens, including blood, urine, wound/tissue, and respiratory specimens (one pathogen per cultured site per patient) of ICU patients. The 4,180 isolates obtained represented 2,580 patients (or 1.62 isolates/patient). Participating study sites were requested to obtain only "clinically significant" specimens from patients with a presumed infectious disease. Surveillance swabs, eye, ear, nose, and throat swabs, and duplicate swabs were excluded. We also excluded anaerobic organisms and fungal organisms. Isolates were shipped to the reference laboratory (Health Sciences Centre, Winnipeg, Canada) on Amies charcoal swabs, subcultured onto appropriate media, and stocked in skim milk at −80°C until MIC testing was carried out.
Antimicrobial susceptibilities.Following two subcultures from frozen stock, the in vitro activities of amikacin, cefazolin, ceftriaxone, cefepime, ciprofloxacin, clarithromycin, clindamycin, daptomycin, gentamicin, levofloxacin, linezolid, meropenem, moxifloxacin, piperacillin-tazobactam, tigecycline, trimethoprim-sulfamethoxazole (SXT), and vancomycin were determined by broth microdilution in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines (7). Antimicrobial agents were obtained as laboratory-grade powders from their respective manufacturers. Stock solutions were prepared, and dilutions were made according to the CLSI guidelines (7a). The MICs of the antimicrobial agents for the isolates were determined using 96-well custom-designed microtiter plates. These plates contained doubling antimicrobial dilutions in 100 μl/well of cation-adjusted Mueller-Hinton broth, and the wells were inoculated to achieve a final concentration of approximately 5 × 105 CFU/ml and then incubated in ambient air for 24 h prior to reading. Colony counts were performed periodically to confirm inocula. Quality control was performed using ATCC quality control organisms: Streptococcus pneumoniae 49619, Staphylococcus aureus 29213, Enterococcus faecalis 29212, Escherichia coli 25922, and Pseudomonas aeruginosa 27853.
For all antimicrobials tested, MIC interpretive standards were defined according to CLSI breakpoints (7). The following interpretive breakpoints (FDA) were used for tigecycline susceptible, intermediate, and resistant: S. aureus (MSSA and MRSA), ≤0.5 μg/ml (susceptible); E. faecalis (vancomycin susceptible), ≤0.25 μg/ml (susceptible); Enterobacteriaceae, ≤2 μg/ml (susceptible), 4 μg/ml (intermediate), and ≥8 μg/ml (resistant).
Characterization of MRSA, ESBL-producing members of the family Enterobacteriaceae, and VRE. (i) MRSA.Potential MRSA isolates were confirmed using the CLSI disk diffusion method and mecA PCR. All isolates of MRSA were tested for Panton-Valentine leukocidin and typed using pulsed-field gel electrophoresis following the Canadian standardized protocol to assess whether the isolates were community-associated or health care-associated MRSA (6, 21-23). Pulsed-field gel electrophoresis fingerprints were analyzed with BioNumerics v3.5 (Applied Maths, Austin, TX) using a position tolerance of 1.0 and an optimization of 1.0. Strain relatedness was determined as previously described (30). Fingerprints were compared to the national MRSA fingerprint database and were grouped into one of 10 Canadian MRSA epidemics (CMRSA-1, CMRSA-2, etc.) as previously described (22). In this study, CA-MRSA and HA-MRSA were defined genotypically and not epidemiologically. Any MRSA isolate with a CMRSA-7 (USA400/MW2) or CMRSA-10 (USA300) genotype was labeled as CA-MRSA, while all other genotypes (e.g., CMRSA-1 [USA600], CMRSA-2 [USA100], CMRSA-4 [USA200]) were labeled as HA-MRSA.
(ii) ESBL testing.Any E. coli isolate or Klebsiella isolate with a ceftriaxone MIC of ≥1 μg/ml was identified as a potential ESBL producer as specified by CLSI. ESBL producers were confirmed using the CLSI double disk diffusion method and retested for their MICs to both ceftriaxone and ceftazidime. PCR and DNA sequence analysis was used to identify blaSHV, blaTEM, and blaCTX-M genes among isolates as previously described (20, 24, 25).
Patient demographics and specimen types.A total of 4,180 isolates recovered from clinical specimens were collected from intensive care units across Canada. The patient sex breakdown was as follows: 59.3% (2,479 of 4,180) of the isolates were collected from males, while 40.7% (1,701 of 4,180) were from females. The patient age breakdown was as follows: ≤17 years, 13.7% (572 of 4,180); 18 to 64 years, 46.7% (1,951 of 4,180); and ≥65 years, 39.6% (1,657 of 4,180). The isolates were obtained from the following specimens: 54.8% (2,292 of 4,180) of the organisms were obtained from respiratory specimens, 17.7% (738 of 4,180) were from blood specimens, 13.9% (581 of 4,180) were from wound/tissue specimens, and 13.6% (569 of 4,180) were from urine specimens.
Most common organisms isolated from ICUs.Table 1 shows the 20 most common organisms isolated from patients in ICUs across Canada. The most common gram-positive cocci included S. aureus (MSSA), coagulase-negative staphylococci/Staphylococcus epidermidis, Enterococcus spp., S. pneumoniae, and MRSA, which together represented 39.5% of all isolates. The most common gram-negative bacilli included E. coli, P. aeruginosa, Klebsiella pneumoniae, Haemophilus influenzae, Enterobacter cloacae, Stenotrophomonas maltophilia, and Serratia marcescens, which together made up 45% of all organisms in ICUs.
Most common organisms isolated by specimen site.Table 2 shows the 10 most common isolates recovered from clinical specimens from the four specimen sites, including respiratory specimens, blood specimens, wound/tissue specimens, and specimens from the urinary tract. Within the respiratory tract, S. aureus (MSSA), S. pneumoniae, and MRSA were the most common gram-positive cocci, accounting for 34.2% of isolates. For gram-negative bacilli, H. influenzae, P. aeruginosa, E. coli, K. pneumoniae, E. cloacae, and S. maltophilia represented 46.1% of isolates obtained. Among blood culture isolates, gram-positive cocci, including coagulase-negative staphylococci/S. epidermidis, S. aureus (MSSA), Enterococcus spp., MRSA, S. pneumoniae, and Streptococcus pyogenes, made up 58.6% of the organisms isolated in ICUs. The most common gram-negative bacilli isolated from blood specimens included E. coli, P. aeruginosa, K. pneumoniae, and E. cloacae, which made up 21.2% of all isolates. For wound/tissue specimens, gram-positive cocci, including S. aureus (MSSA), coagulase-negative staphylococci/S. epidermidis, Enterococcus spp., MRSA, and S. pyogenes, made up 55.2% of the total isolates. The most common gram-negative bacilli isolated from wound/tissue specimens were E. coli, P. aeruginosa, K. pneumoniae, E. cloacae, and S. marcescens, which made up 28.8% of all isolates. From the urinary tract, the most commonly isolated organisms were gram-negative bacilli, including E. coli, K. pneumoniae, P. aeruginosa, E. cloacae, Citrobacter freundii, Klebsiella oxytoca, and Proteus mirabilis, which made up 75.1% of isolates. Gram-positive cocci obtained from the urinary tract most commonly included Enterococcus spp. and S. aureus, which made up 17.2% of isolates.
Characteristics of MRSA.Of the 197 MRSA isolates (22.3% of all S. aureus isolates) isolated from ICUs, 179 (90.9%) were HA-MRSA isolates, while 18 (9.1%) were CA-MRSA isolates. Seventeen of 18 (94.4%) CA-MRSA isolates were positive for Panton-Valentine leukocidin using PCR. Eleven of 18 (61.1%) CA-MRSA isolates belonged to the Canadian MRSA epidemic 10 (CMRSA-10) (USA300) genotype, while the CMRSA-7 (USA400/MW2) genotype occurred in 38.9% (7/18) of CA-MRSA isolates. A thorough analysis of MRSA isolates, including HA-MRSA isolates from the CAN-ICU study, is available from reference 34.
Characteristics of ESBL-producing E. coli.ESBL-producing E. coli and K. pneumoniae occurred in 3.5% (19 of 536) and 1.8% (4 of 224) of isolates, respectively. The most common genotype of the ESBL-producing E. coli was CTX-M-15 at 73.7% (14/19), followed by CTX-M-2 at 10.5% (2/19), and CTX-M-1, CTX-M-9, and CTX-M-14 each at 5.3% (1/19 each). A thorough analysis of ESBL-producing E. coli isolates from the CAN-ICU study is available from reference 34.
Characteristics of VRE.Of the 17 VRE isolates, 76.5% (13/17) were Enterococcus faecium, while 23.5% (4/17) were Enterococcus faecalis. The most common genotype was vanA (88.2% [15/17]). A thorough analysis of VRE isolates from the CAN-ICU study is available from reference 34.
Antimicrobial susceptibility.The antimicrobials tested and percentages of isolates determined to be intermediate and resistant are listed in Table 3 (gram-positive cocci) and Table 4 (gram-negative bacilli). For MRSA, no resistance to daptomycin, linezolid, tigecycline, and vancomycin was observed. Resistance rates for MRSA were as follows: clarithromycin, 89.9%; clindamycin, 76.1%; fluoroquinolones, 90.1 to 91.8%; and SXT, 11.7% (Table 3). For methicillin-resistant S. epidermidis (MRSE), no resistance to daptomycin, linezolid, and vancomycin was observed. No FDA breakpoints are available for tigecycline and MRSE, but when MRSA breakpoints were applied, MRSE resistance to tigecycline was 0%. Resistance rates for MRSE were as follows: clarithromycin, 96.0%; clindamycin, 92.0%; fluoroquinolones, 96.0 to 100%; and SXT, 88.0% (Table 3). For Enterococcus spp., no resistance was observed to daptomycin and tigecycline (using E. faecalis breakpoints). Resistance rates for Enterococcus spp. were as follows: clarithromycin, 65.9%; fluoroquinolones, 51.0 to 53.4%; piperacillin-tazobactam, 21.1%; vancomycin, 6.8%; and linezolid, 1.8% (Table 3).
For E. coli, no resistance to amikacin, meropenem, and tigecycline was observed (Table 4). Resistance rates for E. coli were as follows: cefazolin, 20.1%; cefepime, 0.7%; ceftriaxone, 3.7%; gentamicin, 3.0%; fluoroquinolones, 21.1%; piperacillin-tazobactam, 1.9%; and SXT, 24.8% (Table 4). Resistance rates for P. aeruginosa were as follows: amikacin, 2.6%; cefepime, 10.2%; gentamicin, 15.2%; fluoroquinolones, 23.8 to 25.5%; meropenem, 13.6%; and piperacillin-tazobactam, 9.3% (Table 4). With K. pneumoniae, no resistance was observed to amikacin, cefepime, gentamicin, and meropenem (Table 4). Resistance rates for K. pneumoniae were as follows: cefazolin, 6.2%; ceftriaxone, 0.4%; fluoroquinolones, 3.6 to 4.0%; piperacillin-tazobactam, 1.3%; tigecycline, 0.4%; and SXT, 8.9%.
MDR.Multidrug resistance (MDR) was assessed only in gram-negative organisms, as no accepted definition exists for gram-positive organisms (Table 5). MDR for gram-negative organisms was defined as resistance to three or more of the following: cefepime, piperacillin-tazobactam, meropenem, amikacin or gentamicin, and ciprofloxacin (adapted from reference 18). The MDR phenotype was most common in P. aeruginosa at 12.6%. A MDR phenotype occurred in 0.2% of E. coli and 0.6% of E. cloacae (Table 5). No MDR phenotype was obtained with K. pneumoniae or H. influenzae.
The CAN-ICU study was the first national, prospective surveillance study assessing antimicrobial resistance in patients in ICUs in Canada. This national surveillance study involving 19 medical centers in major population centers in 9 of the 10 provinces in Canada found that more than half of all isolates recovered from clinical specimens in the ICUs were respiratory in origin (Table 2). This was the case in all ICUs across Canada, irrespective of patient age and gender. The remaining half of all specimens from ICUs were from blood specimens, wound/tissue specimens, and urine specimens. The observation that more than half of all infections in the ICU are respiratory in origin, followed by blood, wound/tissue and urinary tract infections has previously been documented (10, 32). Klevens et al. reported that of the deaths associated with health care-associated infections in U.S. hospitals (National Nosocomial Infections Surveillance [NNIS] in 2002), approximately 36.3% were respiratory infections, 31.0% were bloodstream infections, 13.2% were urinary tract infections, and 8.3% were surgical site (wound) infections (15). We report that the 10 most common isolates recovered from 80% of all clinical specimens in the ICU were MSSA, E. coli, P. aeruginosa, H. influenzae, coagulase-negative staphylococci/S. epidermidis, Enterococcus spp., S. pneumoniae, K. pneumoniae, MRSA, and E. cloacae (Table 1). This observation that gram-positive cocci, including MSSA, Enterococcus spp., S. pneumoniae, and MRSA, are the most common gram-positive isolates recovered from clinical specimens in ICUs has been previously documented (12). The recent finding by Lockhart et al. (18) that of the gram-negative bacilli reported to cause infections in ICUs in the United States from 1993 to 2004, P. aeruginosa (22.2%), E. coli (18.8%), K. pneumoniae (14.2%), and E. cloacae (9.1%) were the most common organisms isolated is consistent with our findings.
The CAN-ICU study documented that MSSA and MRSA are important isolates recovered from clinical specimens, including respiratory tract specimens, bacteremia, and wound/tissue specimens in all ICUs in Canada. MRSA made up 22.3% of all staphylococci, and surprisingly, 9.1% of all MRSA in the ICU were CA-MRSA. This has not been previously documented in Canada and shows the rapid evolution of CA-MRSA in ICUs across Canada. All 18 of the CA-MRSA were made up of either USA400/MW2 (CMRSA-7) or USA300 (CMRSA-10) genotypes. These two genotypes are the two primary genotypes that have been reported across North America (4, 6, 13, 22). The CAN-ICU study also showed that VRE made up 6.7% of all enterococci, with the vanA genotype (mostly E. faecium) making up 88.2% of all VRE. Previous data have suggested that E. faecium with the vanA genotype is the predominant genotype in North America (8, 33). This relatively low level of VRE across Canada has been documented previously and shows the lack of spread of VRE across the country (33). The low level of VRE in Canadian ICUs may reflect the ubiquitous active surveillance programs in Canadian hospitals that have been reported to prevent VRE colonization and bacteremia (14, 29).
This study is the first to document that ESBL-producing E. coli bacteria are becoming more common than ESBL-producing Klebsiella spp. in Canadian ICUs. ESBL-producing E. coli isolates made up 3.5% of all E. coli isolates, whereas ESBL-producing K. pneumoniae represented 1.8% of all Klebsiella species. All 19 of the ESBL-producing E. coli isolates displayed a MDR phenotype, with 84.2% demonstrating concomitant resistance to fluoroquinolones and 63.2% demonstrating resistance to SXT. This study has shown that blaCTX-M-15 was the predominant genotype (73.7%) of ESBL-producing E. coli in Canada. Other studies assessing ESBL-producing E. coli have shown that the CTX-M genotype is spreading rapidly in both community and hospital settings (3, 17, 19, 20, 24, 25). Pitout et al. investigated the molecular epidemiology of ESBL-producing E. coli isolates collected from 2000 to 2005, inclusive, in the Calgary Health Region in Canada (25). These investigators reported that 64% (354 of 552) of ESBL-producing E. coli isolates were positive for blaCTX-M genes by PCR, with CTX-M-14 (59.6%) and CTX-M-15 (36.2%) reported most commonly. This study highlights the rapid spread of MDR ESBL-producing CTX-M-15 E. coli in Canadian ICUs. This genotype may be spreading rapidly due to the extensive use of expanded-spectrum cephalosporins and fluoroquinolones.
This study, along with previous studies, highlights that antimicrobial resistance is high in patients in ICUs and based on other studies is higher in patients in the ICU than in patients in other regions of the hospital, such as medical/surgical wards, emergency rooms, and outpatient clinics (1, 10, 16, 18, 26). Resistance rates for MRSA were very high with fluoroquinolones, macrolides (such as clarithromycin), as well as clindamycin (range, 76.1% to 91.8%), and lower with SXT (11.7%). These resistance rates are consistent with previous reports (22). Thus, SXT still represents a reasonable empirical treatment for mild to moderate infections (e.g., skin and soft tissue infections) caused by CA-MRSA or HA-MRSA. All MRSA isolates were susceptible to vancomycin, linezolid, tigecycline, and daptomycin. Likewise, all MRSE isolates were susceptible to vancomycin, linezolid, tigecycline, and daptomycin, while no Enterococcus spp. proved to be resistant to tigecycline and daptomycin. As in previous studies, we document the lowest rates of resistance for gram-negative bacilli with cefepime, meropenem, and piperacillin-tazobactam (18, 26). Although only limited comparative data are available, we also report low resistance rates in gram-negative bacilli from ICUs with amikacin (18). This likely reflects the declining usage of aminoglycosides in favor of increasing fluoroquinolone usage. Fluoroquinolone resistance, on the other hand, was high in E. coli (21.1%) and P. aeruginosa (23.8 to 25.5%), which is consistent with other reports (18, 26), and reflects extensive fluoroquinolone usage (16). Lockhart et al. (18) documented increasing prevalence of MDR gram-negative bacilli in U.S. ICUs. Although our definition of multidrug resistance for gram-negative bacilli (resistance to three or more of the following: cefepime, piperacillin-tazobactam, meropenem, amikacin or gentamicin, and ciprofloxacin), was slightly more restrictive, our MDR resistance rates of 12.6% with P. aeruginosa were somewhat higher than Lockhart et al. (18) at 9.3%. In contrast, MDR rates in Canadian ICUs of 0.2% with E. coli, 0.6% with E. cloacae, and 0% with K. pneumoniae are lower than those in U.S. ICUs at 2.0%, 5.9%, and 13.3%, respectively. Why MDR rates are higher in Canada with P. aeruginosa and lower with members of the family Enterobacteriaceae (E. coli, E. cloacae, and K. pneumoniae) is unclear but may be due to the lower prevalence of ESBL-producing Enterobacteriaceae in Canada (34). MDR ESBL-producing E. coli isolates were all susceptible to the carbapenems, ertapenem and meropenem, as well as tigecycline. As nosocomial infections in the ICU are frequently MDR (a characteristic often associated with prior antimicrobial use) (16), some have suggested that involvement of an infectious diseases specialist may help to improve cure and minimize further resistance development (10).
Our study has several limitations including the fact that we cannot be certain that all clinical specimens represented active infection. In the CAN-ICU study, we asked centers to obtain "clinically significant" specimens from patients with a presumed infectious disease. Although all of the isolates may not represent actual infection from patients, we believe that most do because we excluded all surveillance swabs, duplicate swabs, and eye, ear, nose, and throat swabs and genital cultures. In addition, we do not have admission date data for each patient/clinical specimen, so we were not able to provide a more accurate description of community versus nosocomial onset. In this study, CA-MRSA and HA-MRSA were defined genotypically and not epidemiologically. Any MRSA with a CMRSA-7 (USA400/MW2) or CMRSA-10 (USA300) genotype was labeled as CA-MRSA, while all other genotypes (e.g., CMRSA-1 [USA600], CMRSA-2 [USA100], and CMRSA-4 [USA200]) were labeled as HA-MRSA. It is known epidemiologically that CA-MRSA genotypes can be associated with HA infections and that HA-MRSA can be associated with CA infections (6). In this study, we screened all E. coli and K. pneumoniae isolates for potential ESBL production using only ceftriaxone, which although consistent with CLSI guidelines, may have missed some SHV-producing K. pneumoniae strains by not also testing ceftazidime. Whether this accounted for the reduced number of ESBL-producing K. pneumoniae bacteria versus ESBL-producing E. coli bacteria is unclear.
In conclusion, S. aureus (MSSA and MRSA), E. coli, P. aeruginosa, H. influenzae, Enterococcus spp., S. pneumoniae, and K. pneumoniae are the most common isolates recovered from clinical specimens in Canadian ICUs. Respiratory tract specimens represent over 50% of all the specimens collected in the ICU. A MDR phenotype is common with P. aeruginosa in Canadian ICUs.
Funding for the CAN-ICU study was provided in part by the University of Manitoba, National Microbiology Laboratory-Health Canada, Affinium Inc., Janssen Ortho Inc., Pfizer Canada and Wyeth Inc.
We thank the investigators and laboratory site staff at each medical center that participated in the Canadian Intensive Care Unit (CAN-ICU) study. The medical centers (investigators) were: Royal University Hospital, Saskatoon, Saskatchewan (J. Blondeau); Children's Hospital of Eastern Ontario, Ottawa, Ontario (F. Chan); Queen Elizabeth II Health Sciences Centre and Dartmouth General/Izaak Walton Killam Health Centre, Halifax, Nova Scotia (R. Davidson); St. Boniface General Hospital, Winnipeg, Manitoba (G. Harding); Health Sciences Centre, Winnipeg, Manitoba (D. Hoban/G. Zhanel); London Health Sciences Centre, London, Ontario (Z. Hussain); Victoria General Hospital, Victoria, British Columbia (P. Kibsey); South East Health Care Corp., Moncton, New Brunswick (M. Kuhn); Hôpital Maisonneuve-Rosemont, Montreal, Quebec (M. Laverdière); St. Joseph's Hospital, Hamilton, Ontario (C. Lee); Montreal General Hospital, Montreal, Quebec (V. Loo); Mount Sinai Hospital, Toronto, Ontario (S. Poutanen); Hamilton Health Sciences Centre, McMaster Site, Hamilton, Ontario (C. Main); Cape Breton Regional Hospital, Sydney, Nova Scotia (K. McVarish); University of Alberta Hospitals, Edmonton, Alberta (R. Rennie); Vancouver Hospital, Vancouver, British Columbia (D. Roscoe); Regina General Hospital, Regina, Saskatchewan (E. Thomas); and St. John Regional Hospital, St. John, New Brunswick (Y. Yaschuk).
CAN-ICU data are also displayed at www.can-r.ca .
- Received 28 November 2007.
- Returned for modification 18 January 2008.
- Accepted 10 February 2008.
- Copyright © 2008 American Society for Microbiology


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Industry News
Gravity Demonstrates Its Product At The Lognet Global Conference
Gravity Supply Chain, voted one of the Top Logistics Technology Companies, to exhibit at the Lognet Global Conference June 24 - 27, 2018 in Bangkok.
This event comes off the back of a recent funding announcement that Gravity has raised over $7 million to continue its global expansion. This latest round of funding was backed by the Singapore based venture capitalist group Wavemaker Partners. Over the past six months the quickly growing tech company has been visibly expanding with their location of its Hong Kong Hub and new customer acquisitions in Australia and New Zealand.
The Lognet Global – 8th Annual Conference provides a unique opportunity for its attendees to get a one on one demo of Gravity's product lines for logistics providers. Gravity, Head of Business Partnerships, Dave Graham will be conducting the demos at booth number 3. Demos can be pre-booked through Lognet Global's online scheduler (http://bit.ly/
Gravity Supply Chain Solutions, voted one of the Top Logistics Technology Companies in 2017, provides managers with real-time visibility over their global end-to-end supply chains so they can be more proactive and effective in reducing costs and identifying issues that will impact customer service levels. Gravity accelerates and streamlines the collection, analysis, and sharing of real-time data to improve collaboration and decision-making among all supply chain partners anytime, anywhere.
Gravity uses Web APIs, AI Bots and proprietary algorithms to unlock and gather data scattered across not just an organization's immediate supply chain, but throughout the multiple tiers that support it. It also collects what is happening out in the world – including the latest weather, labor strikes, the impact of natural disasters, providing you with instant awareness of potential supply chain disruptions.
Gravity will be holding meetings and demonstrations during the visit to the show from 24th June to 28th June 2018. We'd love for you to stop by and see how Gravity can help you grow your business this quarter. We'll be doing demonstrations of our solutions for Purchase Order Management, Vendor Management, and Real-Time Shipment Tracker.
Book a meeting with us using the one-on-one scheduler or the link to our website:
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"According to an email obtained by the Star, the organization has $1 million in outstanding payments, a budget shortfall of $200,000 for the first six months of this fiscal year, and a $250,000 credit line that's maxed out most weeks." (1).
Monthly Archives: May 2015
Gay & LGBT Agenda – May 23rd, 2015
Seven items in total…
U.S: Parents enraged over planned lessons on "sexual fluidity and spectrum" – the idea that there's no such thing as 100 percent boys or 100 percent girls
Canada: Mother claims her five year-old "daughter" is having nightmares and panic attacks "because she identifies as a girl, but the Catholic school board has insisted she use a separate, gender-neutral washroom"
Scotland: Church of Scotland General Assembly votes to allow congregations to appoint gay ministers who are in "civil partnerships"
Obama & America's Decline – May 23rd, 2015
Immigration issues…
Federal immigration court back-log now more than 445,000 cases
DHS use of "prosecutorial discretion" in immigration enforcement compromises national security and public safety – see here and here.
Let Syrian "refugees" revitalize Detroit? – The governor's "Michigan Office for New Americans" wants the refugee ceiling raised by 50,000 specifically for this purpose…
"Nature / Environment / Critters" May 22nd, 2015
Nine items in total…
U.S: Injured cat becomes "something of a nurse" at the emergency shelter that took him in
Hungary: Almost 1,000 acres of corn grown with illegal-in-Hungary genetically modified seeds have been destroyed
Peru: Police officer and two farmers dead following clashes over open-pit mining project
Is "embarrassing employer" dismissal a threat to free speech?
Recently in Toronto a female television reporter confronted two men who ran up to her microphone and yelled the obscenity known as "FHRITP". One of these men was fired from his job as a result, igniting a firestorm of controversy over his being fired for actions he took on his own time, away from the workplace. One aspect of this matter which has not been directly addressed, to my knowledge, is the chilling effect on free speech if this precedent should be broadened to include any utterances which could be considered to be "inappropriate" or "politically incorrect".
Canada Family Action: Current activities and appeal for funds
Read the Canada Family Action briefing "Did the Federal Government really tell teachers it's okay to diagnose and treat my child for complex mental health issues?" here.
Read about an upcoming presentation in Alberta by John Carpay, B.A., LL.B., President of the Justice Centre for Constitutional Freedoms here.
You can sign up to receive Canada Family Action's monthly email newsletter here.
You can donate here.
Obama & America's Decline – May 21st, 2015
Some analysis and background on race-based tensions and social upheaval in the U.S.
Five items in total…
Black Republican Walter Hudson suggests that Blackness is defined by how you think, not how you look – "If race is a worldview rather than a skin color, then racism is objecting to that worldview rather than objecting to skin color. This explains why anyone who rejects the Marxist undercurrent of the Black Lives Matter movement can expect to be labelled racist, even if they happen to be black."
The astonishing self-entitlement of the welfare lobby: "Every poverty statistic is presented as if it were evidence of our guilt, when it's actually evidence of our incredible generosity."
Military & Intelligence News – May 20th, 2015
Six items in total…
U.S: Russia's Su-35S "Flanker E" can jam the radar and sensors of even the most advanced US fighter planes
U.K: Able Seaman reveals "serious security and safety breaches" in Trident submarine operations in detailed on-line posting
North Korea: Claim to have successfully fired a missile from a submarine greatly increases threat to South Korea, Japan and the US
China – May 19th, 2015
Seven items in total…
China's challenge to U.S. trade and financial dominance may involve gold – 3,510 metric tons of it
Europol smashes large organised crime money-laundering network in Spain run by Chinese citizens "thought to be the subsidiary of an even larger criminal network based in China"
Interest rate cuts gamble on stimulating the economy to get over recent downturn "without any major disruptions"
Muslims and the West – May 18th, 2015
Eight items in total…
Italy: Schoolboy of "African origin" punches 12-year-old girl for wearing a crucifix
Canada: "Muslim Brotherhood gripping sections of Canada's diverse Muslim community"
U.K: Rape gangs, terrorists, trafficking children – an analysis of Islam-related issues in Britain last month


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Welcome new Assistant Principal: Mr. Carl Berryhill
23 July 2019
Becky Bueche/CREW
(GWIN) - Hoover City Schools proudly welcomes Carl Berryhill to Gwin Elementary School as its new Assistant Principal. Berryhill has taught Social Studies since 2006, most recently teaching 6th grade at Simmons Middle School where he was also served as their Safety Coordinator.
Berryhill holds his Bachelor of Science in Education and his Master of Arts in Sports Management degrees from The University of Alabama. While working on his graduate degree, he served as a graduate assistant student manager for the University of Alabama football team. Recently, Berryhill received his Master of Arts in Education in 2015, majoring in Education Leadership, from The University of Alabama, Birmingham.
Berryhill began his teaching career in sixth-grade social studies at Hamilton Middle School in the Marion County (AL) School System. He continued in that role until he came across an opportunity at Brock's Gap Intermediate in 2012. There, he served as the school's lead ELI (Engaged Learning Initiative) Facilitator and served as the Junior Varsity Offensive Line Coach for Hoover High School's football team under Coach Josh Niblett. In 2018, Berryhill moved due to rezoning to teach sixth-grade social studies at Simmons Middle School.
In addition to teaching, Berryhill also served as interim assistant principal at Brock's Gap Intermediate School during the spring semester of the 2016-2017 school year.
Berryhill has been happily married to Stacia, a third grade teacher at Brock's Gap Intermediate School for eleven years. They have been blessed with two beautiful daughters: Emma Kate, 10, and Addison, 7. Speaking about his new position, Berryhill says that he is "...very excited to be the Assistant Principal at Gwin Elementary, and he looks forward to the year to come."
Carl Berryhill brings to Gwin a wealth of experience and knowledge garnered from his years of teaching and coaching, and we are proud to have him serve the community, staff, and students of Gwin Elementary.


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Ferry House Hostel- Tarbert
The Ferry House Hostel is located in the heart of the village of Tarbert, one mile from the Tarbert/Killimer car ferry which links Killarney and Dingle in Kerry to Doolin and Cliffs Of Moher in Clare.... More...
Shannon's central location on Ireland's west coast makes it a handy place to stay. You'll be within easy reach of the region's beauty spots and close to one of the country's main airports. Arm yourself with a camera and walking boots because the region's sandy beaches, rocky cliffs and limestone pavements are renowned all over the world and well worth exploring. You'll also find live music galore, cultural festivals and cool bars in nearby Limerick, alongside artisan crafts and traditional pubs in the small towns surrounding Shannon.
You can expect a Shannon hostel to be homely, giving you a warm welcome to the town. Options include an 18th-century stone building with crackling open fireplaces, and cosy stays just 5 minutes from the airport. Some hostels in Shannon have snug common areas for getting to know fellow travellers over an Irish coffee, and kitchen areas and a barbecue for whipping up a shared dinner. You'll find options with comfortable private rooms and in-room televisions.
The Shannon region covers the counties of Clare and Limerick, so there are plenty of places to visit. You can spend time in the live music-filled bars of Limerick City or the windswept wilds of the Burren National Park. Ennis is a nearby town with winding streets and Irish pubs, plus historic remains of medieval abbeys and castles. There are plenty of small towns in the region, worth a visit for their thatched cottages and traditional crafts.
The craggy landscapes of the Shannon region are its star attractions. You can take a trek up the Cliffs of Moher (there are steps to help you!) for an incredible view of the Atlantic, or wander the limestone slabs of the Burren and discover ruins from the Stone and Iron Ages. Head to Limerick for year-round festivals and nightlife – look out for whiskey and craft beer joints. You'll find glorious golden beaches and a sheltered ocean pool along the coastline of Clare.
Shannon airport is one of Ireland's main international airports. The two closest cities are Ennis (24km north) and lively Limerick (24km south). There are plenty of car rental options or you can reach the bright lights of Limerick by bus from the airport in around half an hour. Ennis is 30 to 40 minutes by bus. You can travel around the region from Shannon town centre by bus.


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Taipei to give free funerals to those who donate organs
The Taipei city government will offer free-of-charge funerals for people who have donated their organs as part of a bid to encourage people to sign organ-donation cards, a newspaper said on Wednesday, dpa reported.
The government passed the measure on holding free funeral for organ donors Tuesday. A health ministry funeral subsidy will go to the deceased who have donated their heart, kidney, liver and pancreas, but the city government plans to extend it to also cover those who have donated corneas, bones and skin, the Liberty Times reported.
If the organ donor is a Taipei citizen, the city government will hold a free-of-charge memorial service, issue a citation and publicly praise the deceased organ donor.
Taipei hopes that hospitals can put the city government in touch with the family members of the deceased who have donated organs.
It will be left up to family members to decide if the deceased person should be publicly praised for the organ donation.
Like many other countries, Taiwan faces a severe shortage of donated organs because Taiwanese traditionally believe one should be buried with the body intact so that the soul can go to heaven.
According to the Taiwan Organ Registry Matching Centre, there are 6,000 people on the waiting list for organ transplants, but each year there are only about 100 donated organs, which come mostly from road accident victims and other deceased people.
The lack of donated organs has prompted hundreds of Taiwan patients, mostly liver and kidney patients, to go to China each year for organ transplants. Taiwan's health ministry discourages organ transplant trips to China because many of the organs transplanted in Chinese hospitals are allegedly harvested form executed prisoners.


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Breeds: The Dog Name Game - the Favorite 'Guess the Word' game of Dog Lovers 4+
Heureo Labs
- Free
- Offers In-App Purchases
iPhone Screenshots
Do you REALLY LOVE puppies & dogs? Can you name each kind of dog in this fun '4 pics' guessing game?
- MEET the CUTEST puppies and dogs of every kind
- 100 dogs to identify
- PERFECT for quick plays
- CHALLENGING FUN for everyone
- LOVED by vets, pet lovers, and dog groomers (just see our reviews)
- DOGGIE TREATS get you hints for the hard names
Why wait? See why thousands of players enjoy this game and rate it 5 stars (doggie treats) every day. Go play 'Breeds' RIGHT AWAY!
What's New
Version 2.1
Updated to fit on all of your iPhone, iPad and iPod screen sizes.
Removed creepy crawly bugs hiding in the code.
Ratings and ReviewsSee All
Educational and fun
Having fun playing this. A good way to pass the time and learn something. Music is ear- friendly too.
Cool game
I rate it four stars because it is kind of a hard game, but still it is one of my favorite apps. :)
Fun and difficult! A really fun combination!
- Seller
- Heureo, LLC
- Size
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- Games
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Requires iOS 6.0 or later. Compatible with iPhone, iPad, and iPod touch.
- Languages
- Age Rating
- 4+
- Copyright
- © 2016 Heureo Labs
- Price
- Free
Game Center
Challenge friends and check leaderboards and achievements.
Family Sharing
With Family Sharing set up, up to six family members can use this app.


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Not having financial goals can lead to poor money management choices. When you don't have something specific in mind to save for, it's easy to slip into the mindset that it doesn't matter how you spend your money - each choice seems as good as any other. The result can be undirected spending on things you don't need or that won't matter soon after you get them home. In general, it's smart to have savings goals. Here's how to identify goals and reach them.
Visualize Financial Goals
Knowing what you're working towards can be a powerful motivator. Being able to visualize what achieving that goal would feel like can help. For example, if your goal is to replace your aging car, visualize driving to work in comfort, or not having to take your car to a mechanic all the time to keep it running. If your goal is a week-long vacation at the beach, think about the sound of the surf and the sight of your kids digging in the sand. Some people find it helpful to post visual reminders of these goals where they'll be seen frequently. You could, for example, use a photo of the car you want to buy as your computer wallpaper.
Describe Your Goal Using Specifics
Julia Belyavsky Bayuk, assistant professor at the University of Delaware's Department of Business Administration, suggests using the acronym SMART when defining your goals. SMART stands for
- Specific
- Measurable
- Attainable
- Relevant
- Time-limited
By defining your goals in these terms, you make them easier to visualize and make achieving them into a more realistic process.
Make Your Goals the Right Size
When your goals are too easy, you achieve them and are done, without much of a sense of accomplishment. While small goals may be a good starting place, to show yourself you're capable of reaching goals, you should prepare to move on to bigger goals. On the other hand, if you set goals that are overly ambitious, you're more likely to give up before reaching them. Your savings goals should be challenging, but not impossible.
Next step: Sign up for Mint and easily track your progress toward financial goals.
Steps for Setting and Achieving Financial Goals
Forum Credit Union suggests a three-step process for reaching your financial goals. Step one is establishing your goal and determining how much time you'll need to reach it. Determining the time frame is simple for some goals, like saving for a vacation this year, but time frames can be less obvious with other goals, like saving for the down payment on a house. For your longest-term goals, like saving for retirement, you might consider working with a certified financial planner for timeline advice.
The next step is critical: figuring out exactly how you're going to achieve your goal. For most people the best way to do this is to look at the monthly budget and determine where the money to reach the goal will come from. If, for example, you're not able to save as much as you want toward your goal every month, you should look for areas in your budget where you can scale back. Could you cut back on restaurant meals or entertainment? You may want to consider opening a savings account and having money directly deposited from every paycheck specifically for reaching your goal.
The final step in reaching your financial goal is maintaining consistency and accountability. Accept that you'll face temptations to slack off or splurge on other things, but understand how doing so will prevent you from reaching your goal. Staying accountable is easier if you review your savings regularly to track your progress. Some people find that sharing their goal with a close friend or relative and asking them to inquire about progress regularly can help with accountability.
Two Primary Goals that Apply to Everyone
If you're not sure what your savings goals should be, there are two savings goals that apply to everyone. First is saving for your emergency fund. This is a savings account that's available for you to tap into in the event of an emergency. Aim for three to six months' worth of living expenses in this account. This is the account you would use if, for example, you lost your job, or ended up in the hospital with a large co-pay to cover.
The second goal that everyone should have is saving and investing for retirement. This is true even if you're in your early twenties and fresh out of college. The younger you are when you start saving, the more you'll get from every dollar you invest in your retirement. If you have children, saving for their education is important, but saving for retirement is more important. You can't get scholarships for retirement, but your kids can get scholarships, grants, and loans for college.
Know what you're saving for, visualize, define, and plan for those goals. Hold yourself accountable and track your progress using great tools like Mint, and you can achieve more than you imagine.
Next step: Sign up for Mint and easily track your progress toward financial goals.


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problems we solve
In recent years, insurance companies have been widely embracing drone technology. Drones are invaluable at all stages of the insurance lifecycle. They can be used to gather data before a risk is insured, to help in preventative maintenance, and to assess damage after an event.
Images of the property to be insured can be obtained prior to providing coverage. Spurred by catastrophic damage from recent hurricanes and other weather events in the United States alone, drones have been given an international stage to truly showcase their effectiveness.
In the wake of these disasters, drones can be deployed not just for insurance companies to help speed up claims, but also for search and rescue efforts. Using a drone to inspect a building after a loss, adjusters and underwriters can obtain the information they need in a fraction of the time it would have taken before. In addition, drones can be operated at a much lower per-hour cost than manned inspection vehicles and offer the ability to collect data on a pre-programmed repeatable track, providing consistency in the inspection data and process.
inspection examples
Roof Damage
Bridge Infrastructure
Utility Lines
Natural Disaster
Fire Damage
roof inspections
Where a typical roof inspection using a ladder takes about an hour and inspections of multiple-story or steep roofs even longer, a drone inspection can capture the necessary images in less than half the time. Speed is important because roofing contractors are booked quickly after a big storm hits. Using drones is also safer for insurance company employees. Giving claims adjusters a drone service that keeps them safely on the ground may seem more expensive than conventional techniques, however, all will agree that the long term increase in safety margin is well worth it since just one accident can de-rail productivity and bring the inspection to a halt.
Drone mapping is a powerful new tool for inspections. A thorough mapping flight allows you to capture hundreds or even thousands of high-resolution images of all four vertical facades of the structure you are inspecting. Additionally, images capture not only the finite detail of all vertical and horizontal surfaces but each image includes geo-referenced data location for easier analysis. Back in the office, or out in the field, it's easy to analyze these highly detailed building survey maps, make measurements, and share comments to help you make better and quicker decisions. Drone mapping gives insurance companies a fast, easy way of accurately documenting the scene, preserving key details while allowing the process of clean-up and reconstruction to begin as quickly as possible.


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via. GM.
From the strange world of approved and rejected Apple App Store apps comes word today that Apple has approved a medicinal Cannabis location app for the iPhone and iPod touch.
And good on them, I say. Medicinal Cannabis use works, alleviates pain, and allows people who need some serious stress relief—say, from cancer—to get that relief and feel great doing it.
The app is based on Ajnag.com, which has existed for a while as a legitimate medicinal Cannabis location site on the Web.
Monday, July 20, 2009
Need Medicinal Cannabis? There's an App For That.
Posted by Kev - S.L.A.B. ENT. at 10:45 AM
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Types of algae growth:
- A pea-soup coloured pond or one containing blanketweed or filamentous green algae (which looks like green cotton wool in the water) are thriving on surplus nutrients and mineral salts in your pond water - especially nitrates and phosphates.
- Remember - if the algae is the only plant form in your pond then that is the one that will grow using all the available light, warm and food sources at its disposal.
- As the water warms up it grows even more quickly.
- Algae growth in Spring outstrips the growth of natural predators like water fleas and many pond plants.
Algae growth:
- New ponds often have early season problems with pea-soup algae but this is due to an imbalance between the nutrients in the water and the amount of plant growth.
- This algae has no fibres to it but the microscopic cells will stain your fingers if you drag them in the water.
- This will normally settle down as the water matures but may take a full year to do so.
- Speed this process with Cloudy Water Treatment
Blanketweed growth:
- Some algae forms filaments or fibres that you can actually pull across the water surface as a mat (or blanket). This is known as blanketweed and this thrives on the nutrients in the pond water too.
- In the short term you can remove excess blanketweed by twisting it on a stick or rake but you need to open out the twists to release any creatures and then remove the debris from the pond edge so that the nutrients in the blanketweed do not leach back to the pond and start the process again.
Algae control:
To control the growth of any algae you need to remove the conditions that it enjoys:
- shade the water so it remains cooler,
- remove surplus nutrients by adding plant growth to act as competition for the free nutrients,
- control the amount of rotting vegetation in the base of the pond that releases surplus nutrients,
- reduce overfeeding of fish that allows surplus to fall to pond base,
- reduce stock levels of fish as they create too many nutrient high waste products in the water
Prevention of algae growth using plants:
Prevention is better than cure:
- Add the right quantity of submerged oxygenating plant growth to use up the ponds nutrients. One third of the volume of your pond water should contain healthy, submerged oxygenating plants.
- Cover half to two thirds of the pond surface area with floating leaved plants (either waterlilies, rafting plants or floating plants) to give shade across the surface to keep the water cool.
- Keep the water moving as some algae forms prefer still water so pump systems can help
- attach this pump to a biological filter to remove nutrients with a UV light system to break down algae strands
Sludge layer:
- a thick layer of sediment sludge on the bottom of the pond will release nutrient. A bit like the nutrient levels released by compost from your compost heap when added to the vegetable patch.
- Treat this foul smelling sludge on the pond base using Mud Muncher on a regular basis
- Remove any excess sediment in Autumn maintenance.
Blanketweed control using Barleystraw:
As a further aid to preventing algae use a barleystraw product that suits your pond size:
- Barley Bio Algae Control for a small pond or container -
- If you have been treating pond algae with Barley Bio and it's fighting back in hot weather, increase dosing frequency, not the dose size
- Barleystraw minibales for a larger volume of water -
Each bale will float on the surface of the pond where the oxygen levels are higher and this increases the effectiveness of the straw.
- Barley minibales are most effective when placed in running water - near a waterfall, pump or filter box outlet.
- all are organic inhibitors to the production of algae growth.


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Biomaterials-based approaches to personalized medicine
Symposium of the Leibniz Research Alliance Health Technologies
Leibniz Health Technologies Symposium | 22.03.2017 | Berlin
Biomaterials-based approaches to personalized medicine
Biomaterials are instrumental in individualized medical technologies targeting regenerative therapies, immunomodulation or diagnostic methods. In addition to direct clinical application, biomaterials play a key role in the development of advanced three-dimensional tissue and disease models as, for example, required in personalized drug screening.
The one-day symposium is organized by Leibniz Health Technologies and its institutes within the area of expertise "Bioactive Interfaces". The event will focus on recent developments in adaptive and bioactive materials for individualized approaches of medical technologies. Beyond recent advances in biomaterials science, the symposium will cover the translational perspective, provide an industrial point of view, and give insights on related aspects of health economy and research policy.
The meeting will be opened by Matthias Lutolf (Ecole Federal Polytechnique Lausanne), a pioneer of cell-instructive polymer matrices, and concluded by Herbert Zeisel (Federal Ministry of Science and Technology). Keynote lectures will be presented by Georg Duda (Charité Berlin), Jürgen Groll (University of Würzburg), Wilfried Weber (University of Freiburg) and others.
The meeting will provide a comprehensive and interdisciplinary view on biomaterials in the context of personalized medicine as well as opportunities for networking. The participation of young researchers and students is encouraged.
Scientific Organizers:
Aranzazu del Campo, Leibniz Institute of New Materials, Saarbrücken (INM)
Martin Möller, Leibniz Institute of Interactive Materials, Aachen (DWI)
Carsten Werner, Leibniz Institute of Polymer Research Dresden (IPF)
Event Organization:
Karina Weber, Leibniz Health Technologies
Jens Hellwage, Leibniz Health Technologies
Sybille Demmler, Leibniz Health Technologies
Leibniz Research Alliance Health Technologies
Sybille Demmler, assistance
Philosophenweg 7 (Zentrum für angewandte Forschung)
07743 Jena
Tel.: +49 3641 948362


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Too Good At Goodbyes.
Sam Smith and Brandon Flynn are Hollywood's newest it couple.
Not really, but maybe.
Paparazzi spotted Smith and Flynn locking lips and holding hands with one another this week. The photos were first published on TMZ via SplashNews. Which is ironic timing considering Sam's new tune, "Too Good At Goodbyes," is about running from love because of its impending doom.
We're living in a really dark time right now, so anyone who finds romance amidst the chaos gets a thumbs up from me. Now it's time for me to go back into my cave and devour cookie dough ice cream see ya.
Thoughts on Smith and Flynn dating? Let us know in Exhale.
And while you're at it… leave a comment and follow us on Facebook, Twitter & Instagram and subscribe to our YouTube channel.


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Listen to the full broadcast of I'm Listening with Metallica, Halsey, Logic, and more
September 10, 2017
It's OK to not feel OK.
On World Suicide Prevention Day, radio stations across the country brought together medical professionals and musicians from all genres to help end the stigma that it's not ok to talk about suicidal thoughts or mental illness in a broadcast called I'm Listening.
Metallica, Halsey, Logic, Krist Novoselic (Nirvana), Jack Antonoff, Gary Allan, Sarah Barthel (Phantogram), and many more joined hosts BJ Shea, Dr. Ursula Whiteside for two hours to talk about ways suicide and mental illness has affected each of their lives individually, and how listeners who might know someone in crises, or who are in crisis themselves, can help.
You can listen to their stories and advice from the full two-hour broadcast below:


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Serbian Patriarch Irinej visited the church of Sveta Trojica in Vraka and the church of St Sergius and Bacchus
On Saturday, May 31, for the first time in the history of the existence of our national minority in the territory of Albania a Serbian Patriarch visited the church of the "Sveta Trojica" of Vraka and members of the Serbian-Montenegrin minority who were in large numbers gathered to honor his visit in front of the church. His Holiness Serbian Patriarch Irenej was accompanied by the Mitropolit of Montenegro Mr. Amfilohije and the Metropolit of Berat Mr. Ignatius of Albanian Orthodox Church.Entering the church His Holiness Serbian Patriarch Irenej was welcomed by the Metropolitan of Berat Mr. Ignatius, in the name of Holy Synod of the Albanian Orthodox Church and His Beatitude Archbishop of Tirana Mr.. Anastas, who thanked the Serbian Patriarch for His arrival in Albania to participate in religious celebrations in Vraka and i Tirana.
After welcoming greetings on this occasion, Patriarch Irenej spoke to religious people.
"This is for me a great gift and grace of God, to visit these beautiful lands, to visit this beautiful church and our brothers and sisters who belong to the Holy Orthodox Church, the great family of the Orthodox nations. I come on behalf of our Holy Serbian Orthodox Church to welcome you and to convey to you the greetings of our church and our people, to you who live here in this country. We are one big Christian family, Orthodox, and no matter in which country we live we are a spiritual family, and our goal is to come together and unite with our Lord. And when we are united with God, then we are close to each other. You live in this blessed country, here live the Orthodox, Roman Catholic and Muslim brothers, although we belong to different religions, we are the people of God. We were all created by God and we are all obliged and invited to pray the Lord in the way that religion teaches us "
Keep and save your Holy Orthodox faith. From the earliest time till now, and hopefully in the future our holy church will live here, that truth of the gospel will be revealed, and that God will teach us to pray, and to respect each other and appreciate following the Lord's wish .
I wish you all the best and God's blessing from this wonderful holy church to be poured on your family and your children and to all of you in this holy temple who are attached with faith and love to God . May God's blessing follow you all the days of your life. Amen, "said in his homily, His Holiness Patriarch Irinej.
On behalf of the Orthodox Association "Sveti Jovan Vladimir" , welcomed on this occasion His Holiness Patriarch Irinej the President Mr. Simo Ajković, who said among other things:
"Your Holiness! Welcome to Shkodra. This is the day which the Lord created to our happiness and to enjoy. The day which generations of Serbs in Albania are waiting for centuries. Your arrival on the fireplace of our ancestors, their graves and for us, their descendants is a great blessing. You know best, Your Holiness, what the suffering passed through the Serbian Orthodox Church in the region. Temples were destroyed, priests persecuted and killed, and the bells fell silent. Persecuting the Lord Jesus Christ, it was the timee of suffering of His followers and believers. When seemed to be no end to our forgetfulness, by the opening of the relics of Saint John Vladimir, King of Zeta and martyr and also the restoration of the Orthodox Church in Albania, headed by His Beatitude Archbishop Anastasi, and the arrival of the Metropolit of Montenegro Amfilohije in Cetinje, at the beginning of the nineties followed by his constant concern for the fate of the rest of our people in Albania, things began to change for the better.
We went back to a life as devoted people and Christians. This temple is the sign of the return to our ancestors' faith and the Holy Trinity in Vraka, which was built by joint efforts of the Albanian Archbishop Anastas and Metropolit of Montenegro Amfilohije.
There's no better formal occasion, and a better reason than your arrival and presence here in Albania, to ask in agreement with His Beatitude Mr. Anastas, during your next visit together to consecrate this sacred temple.
Your arrival is a great blessing for the country and for the people, and the great bridge of peace, love and understanding.
Welcome and for many years " concluded his greeting Mr. Simo Ajković.
The Serbian language course attendants at the Association "Moraca- Rozafa" and Orthodox youth of Shkodra and Vraka organized in honor of Serbian Patriarch a program of recitations and traditional songs and folk dances, gathered in the cultural group "Obilic" from Shkodra.
During the program the President of the Association of Serbian-Montenegrin minority in Shkodra, "Moraca- Rozafa" Mr. Brajović Pavlo welcomed His Holiness Patriarch Irinej who said:
"Your Holiness! Let me use this occasion to transmit to You our greetings in the name of Serbs and Montenegrins in Albania. Your arrival in this country is of great importance for the life of our community. We are confident that Your presence here will infuse new strength in the further struggle for the preservation of the identity of our people, who for decades were severely deprived. Association, "Moraca- Rozafa" for more than two decades brings together Serbs and Montenegrins, so that we can preserve the language, religion, customs and culture of our people. The first ten years we had no help from those who were legally obliged to provide it to us. On the contrary, we were severely persecuted. In the last ten years, thanks to the care and efforts of Metropolit of Montenegro Amfilohije, we had spiritual and material support. Thanks to this, we have not only survived but also developed our activities. We also had the support of the Republic of Serbia, which has, through the Ministry of Diaspora and the Ministry of Culture met our needs. This assistance has primarily focused on the creation of conditions for learning Serbian language and culture. So far we have realized about thirty projects in the area. But there are plenty of things that have not been resolved, and which for us are vital. We expect the Republic of Serbia to provide long-term and stable support to our efforts. Since Serbia timely is resolving the issue of citizenship of the Serbian minority in countries of the region, we expect that the issue of obtaining Serbian citizenship and our minority in Albania to be also resolved. Please, Your Holiness, help us in this matter.
Your current visit and any future for Serbs and Montenegrins in Albania will be new encouragement to hold on in times to come.
We thank the Lord and Saint John Vladimir for honoring us with your presence and blessing, and it's our generation graced to welcome for the first time in our history the Serbian Patriarch in Vraka and Shkodra. Welcome always ", said Mr.. Pavlo Brajović.
The ceremony on the occasion of the visit of Serbian Patriarch Irinej of Vraka and Shkodra, was attended by priests of the Mitropoly of Montenegro and the Albanian Orthodox Church, the Ambassador of Republic of Serbia in Tirana Mr. Miroljub Zaric, Director of the Office for Cooperation with churches and religious communities in the Republic of Serbia Mr. Mile Dr. Radojevic and associates, as well as many believers from Vraka, Shkoder and Montenegro. Gathered people was composed by the Orthodox and members of other religions of our people and our friends, who had come to welcome and greet the Serbian Patriarch.
VISIT OF SERBIAN PATRIARCH TO CHURCH OF ST SERGIUS AND BACCHUS FROMT THE 13th CENTURY
After some refreshments, Patriarch Irinej, Mitropolit Ignatius and Amfilohije, the clergy, representatives of the Serbian organizations and delegation of the Serbian and the Albanian Orthodox Church, visited the remains of the ancient monastery of St. Sergius and Bacchus from the 13th century, on the river of Buna, where it is assumed that Serbian kings from the famous dynasty of Vojislavljevićs. were buried.
Bowing to the ruins of the monastery, His Holiness The Patriarch prayed to God for the repose of the soul of Serbian kings, saying, "May the Lord forgive the souls of those who rest here, bless us to continue the history and life, in order to pass on it to those who come after us" .
After touring in Vraka, Shkodra, of the ancient monastery of St. Sergius and Bacchus delegation of the Serbian Orthodox Church headed to Tirana to participate in the consecration of the Cathedral of the Resurrection of Christ.
The visit of Serbian Patriarch in Shkodra and Vraka would not have been successful without the unreserved cooperation and engagement of law enforcement who guaranties the necessary security conditions despite the announced protest by nationalist circles in Albania.


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When searching an ERP solution for your business, you will be given 100's of products to select. As you decide your options, one of the key decisions you will need to make is whether to select a cloud ERP Software or On-premise ERP Software.
The basic difference between the both the options is: On-premise ERP Software is deployed locally in your company and then managed by your IT staff while cloud ERP software also called Software-as-a-Service (SAAS) is provided as a service. In SAAS ERP model data are managed centrally by the ERP software vendor and accessed through the internet using a web browser and mobile apps.
Small and medium businesses are adopting Cloud-based ERP Software, but there are several reasons why a company might choose a traditional, on-premise ERP solution.
This post elaborates the advantages and disadvantages of Cloud ERP Software and On-premise ERP software. And how you can decide which is suits best your company.
Cost :
Cloud-based ERP Software (SAAS) is generally priced as a monthly or annual subscription, with additional cost for training and support. The advantages of this pricing model are your software expenditure can be OPEX instead of CAPEX. Minimal initial investment and easy to forecast. You can avoid hardware such as servers and maintenance cost. All the backups and maintenance will be taken care by the vendor.
On-premise ERP software is a one-time investment for the license (perpetual license), usually license is based on the size of the company and number of users. Generally, On-premise ERP software will be CAPEX. Selecting the right implementation partner with Industry (domain) knowledge and experience are the key factors. There are many ERP failure stories and court cases are filed against implementation partners because of poor implementation.
In cloud-based ERP solutions software is hosted on vendor server and accessed through a web browser or mobile apps. Whereas in on-premise solution software is hosted locally on the company server and accessed through LAN and VPN when outside the local area network.
Typically cloud-based ERP implementation is much faster than On-premise ERP software. The average time for Cloud will be approximately 2 to 3 months whereas On-premise ERP implementation can take 6 to 24 months depends on the company size, users, locations, and customizations.
The Software vendor takes care of data security, but company's IT department should work with the software service provider to make sure the highest level of security. Even though the software is hosted on the highly secured data centers organizations data are still under threat. In the past, we have seen many hacks and data center outages.
On-premise ERP Software is generally considered as more secure because the server and software are installed locally in the company premises. Access can be closely monitored and controlled. Proper security policy and timely data backup can save the company from any kind of security threat.
Cloud ERP system comes with the standard features and only minimal customization is possible because as a customer you will have less access to the source code. Therefore, you will be forced to use the existing features and work around solutions.
On-premise ERP systems are highly customizable as per your requirements and business process. Every business is unique in the operations, culture and business process; therefore, a customized ERP software add more value, streamline the operations and saves time and money in the long run.
Both the On-premise and Cloud version have their own advantages and disadvantages. Selecting the right ERP Software and architecture is completely depends on the Organizations Management, Stakeholders, Security policy, Budget, and Vision. If you are still confused and need more clarity before making the decision reach us now for free consultation.
Brainsphere IT Solutions provides both on-premise and cloud ERP software solutions, check out our Products page for more information about our solutions.
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Under-the-Radar Prospects: UNC WR Ryan Switzer
When it comes to adding weapons for Carson Wentz, there are multiple prospects in the middle rounds that could offer the Eagles some value. Enter North […]Read
no responses. February 17, 2017 Gayle Saunders
Mayock lists CB Sidney Jones as his Top CB
NFL Media draft analyst, Mike Mayock, recently named Washington CB Sidney Jones as his top cornerback prospect for the 2017 draft. While Mayock usually leaves no […]Read
no responses. February 15, 2017 Ryan Neal
Eagles mock draft roundup: Eagles select Mike Williams in Mel Kiper's latest mock
With the 14th pick in the NFL Draft, the Eagles get some help for Carson Wentz. Yes, Mel Kiper has the Eagles taking Clemson wide receiver, […]Read
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Eagles mock draft roundup: Charley Casserly has the Eagles taking Mike Williams
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Kevin Muscat says that the decision to award a penalty against Corey Brown for a handball inside the penalty box may set a precedent for any player who accidentally handles the ball inside the box. In a recent match between Melbourne Victory and Perth Glory, the latter were able to take the lead when Corey Brown accidentally touched the ball from a few metres away when Neil Kilkenny flicked in his direction. Worldwide, referees do not give penalties for such incidents since there is very little time for a player to react and take his hand out of the way.
However, referee Jarred Gillett decided to hand a penalty to the incident and even the VAR decision did not change matters. Perth Glory opened the scoring with this penalty and went on to win the game with a 2-1 score.Muscat was understandably upset after the match and he said that there was little Brown could have done for the incident. In such a situation, it is wrong for the referee to hand a penalty, which may serve as a precedence for future incidents of such nature. However, Perth Glory manager Tony Popovic did not tend to agree with Kevin Muscat and admitted that it was a penalty.
World Cup Group D


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IGAD center for Pastoral Areas and Livestock Development (ICPALD) convened a bilateral crossborder planning meeting between Kenya and Uganda from 4- 6th December 2019 in Lodwar, Turkana County, Kenya to develop a harmonized trans boundary animal diseases surveillance and vaccination calendar for 2020 between Kenya and Uganda . The one-day meeting focused on planning of harmonizing/ synchronizing prevention and control TADs in the shared cross border areas of Karamoja cluster that covers West Pokot and Turkana counties in Kenya and nine districts in Karamoja region of Uganda. The meeting had twenty three participants drawn from the Ministry of Agriculture, Animal Industry and Fisheries (National and districts) Uganda, National/ County governments (Kenya), VSF-Germany- Kenya, Mercy Corps- Uganda and ICPALD.
The key actions conducted and recommended;
- A six month harmonized surveillance and vaccination calendar against common TADs was developed between West Pokot county & Amudat district and between Turkana county and Kaabong, Kotido and Moroto districts
- 5th December, 2019 – at Lokiriama ward, Loima sub-county, Turkana County, Kenya: Lomeyan Ewoi, Lokiriama ward administrator was nominated by the Agriculture CEC to launch the exercise at the cross border area with Uganda. Many pastoralists presented and had their livestock vaccinated against Lumpy Skin Disease (LSD) and Peste Des Petits Ruminants (PPR). The animals were treated against various ailments and dewormed alongside the use of ectopour to control external parasites including ticks.
- 6th December, 2019, at Rupa Sub-County, Moroto district, Uganda: Vaccination against LSD and PPR was launched by Edward Echo on behalf of the Chief Administrative Officer, Moroto district.
- Similar and regular coordinated cross border vaccination will be advocated on both sides as per the agreed calendar
ICPALD acknowledges and aprreciates FAO for providing financial support.


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By Nicole D. Prysby, J.D.
Attorneys General from 32 jurisdictions argue in an amicus brief that they are authorized to enforce the CFPA regardless of whether the CFPB has already begun an enforcement action.
Attorneys General from 31 states and the District of Columbia argue that the Consumer Financial Protection Act (CFPA) authorizes their enforcement whether or not the Consumer Financial Protection Bureau has already acted. The AGs made the argument in an amicus brief filed in the federal Third Circuit Court of Appeals in an appeal by Navient Corporation after Navient failed to have claims against it brought by the Pennsylvania AG dismissed. Navient argued in the district court that the CFPA precludes Pennsylvania from bringing a parallel enforcement action that is similar to a claim already brought by the CFPB and that Pennsylvania's consumer protection law is preempted by the Higher Education Act (Commonwealth of Pennsylvania v. Navient Corp., Case No. 19-2116).
As previously reported, the Pennsylvania AG filed a complaint against Navient in 2017, alleging that the company violated the CFPA and Pennsylvania's Unfair Trade Practices and Consumer Protection Law (CPL). More specifically, the Pennsylvania AG claimed Navient harmed student loan borrowers by marketing risky and expensive subprime student loans that it knew, or should have known, were likely to default and by making misrepresentations while steering borrowers into costly forbearances instead of enrolling them into more affordable income-driven repayment plans. The district court rejected arguments from Navient that the claims should be dismissed because the CFPA precludes Pennsylvania from bringing a parallel enforcement action that is similar to a claim already brought by the CFPB and that the CPL is preempted by the Higher Education Act (see Banking and Finance Law Daily, Dec. 19, 2018). Navient appealed, and both Navient and the Pennsylvania AG have filed initial briefs with the Third Circuit. State attorneys general from 31 states and the District of Columbia signed on to a brief filed in support of Pennsylvania.
The amici states argue that the CFPA authorizes their enforcement whether or not the CFPB has already acted. The notice and intervention provisions in the CFPA are consistent with concurrent state enforcement action—for example, the notice provision (12 U.S.C. § 5552(b)(1)(C)(iii)) expressly contemplates that there may already be a pending CFPB "action" at the time of the state's pre-suit notice. The statute's use of the word "action" is not (as Navient argues) limited to pending regulatory actions. Contrary to Navient's suggestion that pre-suit notice would be futile where the CFPB has already filed a lawsuit, such notice is arguably most useful when the CFPB is engaged in pending litigation, because notice gives the agency an opportunity to coordinate with the state to ensure that neither party assumes a litigation position that would undermine the other's action. The CFPA also allows the CFPB to intervene in a state's action under appropriate circumstances (12 U.S.C. section 5552(b)(2)) which is consistent with concurrent state enforcement actions. Where Congress did seek to limit states' enforcement authority under the CFPA, it did so expressly. For example, states cannot enforce mortgage regulations promulgated by the CFPB when the federal agency has already initiated an action against a party. In addition, there is no merit to Navient's complaints that concurrent state enforcement actions "waste judicial resources and create inconsistency" and that "serious constitutional concerns" would arise if fifty state attorneys general were able "to enforce federal law independent of the President" or other federal authority. No court has ever found that the Constitution forbids Congress from conferring enforcement authority on anybody other than a federal officer or agency.
The state AGs also argue that exempting student loan servicers from state consumer protection laws would leave millions of Americans vulnerable to unfair and deceptive practices and that states are uniquely positioned to protect their own residents from these practices. Also, the Higher Education Act does not preempt state consumer protection laws because its express preemption provision is narrow and only applies to state laws compelling specific disclosures, and there is no conflict between the Higher Education Act and state consumer protection laws.
Attorneys: John Abel, Office of Attorney General of Pennsylvania, for Commonwealth of Pennsylvania. Daniel T. Brier (Myers Brier & Kelly) for Navient Corp.
Companies: Navient Corp.
MainStory: TopStory CFPB DelawareNews EnforcementActions Loans NewJerseyNews PennsylvaniaNews Preemption VirginIslandsNews UDAAP
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The Supplier for the Independent
Spray foam insulation manufacturer providing energy-efficient systems, while leading the industry in quality, experience & support.
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We are dedicated to the development of high-quality Urethane Systems with low VOC signatures and an environmentally friendly, raw material base. Our petroleum and natural-based products are third-party tested, meeting and often times exceeding industry standards.
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As a spray foam insulation supplier for the independent, we work with you to determine the best products for your project or contract work. Our spray foams are built to help you get the job done, faster, with a consistent spray from start to finish and a quality mix that's easy on the gun (with noticeably less clogging than competitors). Secure a job well done with a firm, energy-saving, seal and enjoy the cost-saving benefits of rebates, tax credits, and green certifications for the long run.
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We were thrilled to be featured on the popular YouTube channel "Building a Better South", which describes exceptional home building from the perspective of industry experts. In this episode, the creators of the show demonstrate the use and value of Natural Polymers Spray Foam in a new home build. They did a remarkable job of describing our product, as well as demonstrating in action. Take a look, and then check out our Open Cell Spray Foam product for yourself.


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PDA Texas
March on the Capitol for Texas Public Education
Join PDA-CENTEX and our Labor brothers and Sisters!
Had enough of stagnant pay, overwhelming health-care costs and inadequate funding for our students? Join us for a rally at the Capitol where we intend to be 10,000 strong telling legislators that we are ready to Speak Out! and Stand Together! for public education.
Texas Represents
Texas Represents at PDA National Conference
PDA NCTX Christmas Party
Saturday, December 8, 2018 at 2pm at the Cleburne office
Selling items in the store helps us keep you all supplied with materials needed for your awesome activism!!!
Time to get involved, plus a message from Lupe Valdez
Click on the link to watch the video. Watch until the end. It's a short one.
Healthcare Press Conference, June 20, 2018
Join us for this event.
204 S. Main St.
Cleburne, TX 76033
We're Busy in North Central TX
Progressive Democrats North Central TX.
Cinco De Mayo Voter Registration and Community Involvement Program. Saturday, May 5, 2018
SDEC Quarterly meeting on April 14, 2018
The SDEC Quarterly Meeting is at the Sheraton Hotel, on April 14 in Austin. Following the Business Meeting, a Grassroots Training Session, titled "Blue Wave," will commence. Like the Fair Shot Training last April, the focus is on organizing County Grassroots efforts. The program is essential to "Get The Vote Out" Precinct Efforts. It starts after Lunch.
PDA North Central Texas / Open House
You're Invited to Our Open House
Progressives have come to Main Street! Literally. And you're invited to see and enjoy the new headquarters of PDA North Central Texas, Indivisible TXJC, Latino Democrats, and allied groups. We're joining forces at our new office located in downtown Cleburne, right across the street from the district office of Republican Congressman Roger Williams (TX-25).
PDA North Central Texas
Sunday, January 14, 2 p.m.
204 S Main Street
Cleburne TX 76033
Come to our Open House to get (and give) your campaign T-shirts, bumper stickers, buttons, and cards. Invitations are extended to all Texas Democratic candidates, precinct chairs, and groups including Progressive Democrats of America, Texas Democratic Women, Stonewall Democrats, Democratic Socialists, and local/county Democratic Party members, as well as interested Independents and the general public.
It's time to let the world know, Loud and Proud: Yes! Johnson County, Texas, DOES have Democrats and Progressives. Lots of us!
Come meet your neighbors, get the scoop on various Democratic clubs who would love to have you join them, and learn how you can help #TurnTexasBlue. Coffee, tea, and light refreshments will be served.
For more information and to RSVP, email email@example.com, or RSVP at https://www.facebook.com/events/532390280470644/
Join our Facebook group: https://www.facebook.com/ groups/PDA.NCTX/
Bob Sheldon
PDA State Coordinator
Lou McCreary
PDA Central Texas
Kat Sanders
PDA North Central Texas
Frank Archuleta
PDA - San Antonio


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