Work stressors, strains and hospital unit performance

Hospital employees who work in an environment with zero tolerance to error, face several stressors that may result in psychological, physiological, and behavioural strains, and subsequently, in suboptimal performance. This thesis includes two studies which investigate the stressor-to-strain-to-performance relationships in hospitals. The first study is a cross-sectional, multi-group investigation based on secondary data from 65,142 respondents in 172 acute/specialist UK NHS trusts. This model proposes that senior management leadership predicts social support and job design which, in turn, moderate stressors-to-strains across team structure. The results confirm the model's robustness. Regression analysis provides support for main effects and minimal support for moderation hypotheses. Therefore, based on its conclusions and inherent limitations, study one lays the framework for study two. The second study is a cross-sectional, multilevel investigation of the strain-reducing effects of social environment on externally-rated unit-level performance based on primary data from 1,137 employees in 136 units, in a hospital in Malta. The term "social environment" refers to the prediction of the moderator variables, which is to say, social support and decision latitude/control, by transformational leadership and team climate across hospital units. This study demonstrates that transformational leadership is positively associated with social support, whereas team climate is positively associated with both moderators. At the same time, it identifies a number of moderating effects which social support and decision latitude/control, both separately and together, had on specific stressor-to-strain relationships. The results show significant mediated stressor-to-strain-to-performance relationships. Furthermore, at the higher level, unit-level performance is positively associated with shared unit-level team climate and with unit-level vision, the latter being one of the five sub-dimension of transformational leadership. At the same time, performance is also positively related to both transformational leadership and team climate when the two constructs are tested together. Few studies have linked the buffering effects of the social environment in occupational stress with performance. Therefore, this research strives to make a significant contribution to the occupational stress and performance literature with a focus on hospital practice. Indeed, the study highlights the wide-ranging and far-reaching implications that these findings provide for theory, management, and practice.

Antibiotic and biocide resistance in Salmonella enterica and Escherichia coli 0157

Bacterial resistance to antibiotics and biocides is a prevalent problem, which may be exacerbated by the commonplace and often unnecessary inclusion of biocides into domestic products. Addition of antimicrobials, to domestic disinfectants has raised concern about promoting microbial resistance and potential cross-resistance to therapeutic antibiotics. This study investigated the potential for resistance in Salmonella enterica serovars Enteritidis, Typhimurium, Virchow and Escherichia call 0157 to commonly used biocides, to identify mechanisms underlying resistance and whether these provided cross-resistance to antibiotics. Salmonella enterica and E. coli 0157 strains were serially exposed to sub-inhibitory. concentrations of erythromycin (ERY), benzalkonium chloride (BKC), chlorhexidine hydrochloride (CHX)and triclosan (TLN). Once resistance was achieved permeability changes in the outer membrane, including LPS, cell surface charge and hydrophobicityand the presence of,an active efflux were investigated as possible resistance candidates. Thin layer chromatography (TLC) and Gas chromatography (GC) were carried out to examine fatty acid and lipid changes in E. coli 0157 isolates with reduced susceptibility to TLN. Cross-resistance was studied by the Stoke's method and standard microdilution assays. Examination of the outer membrane proteins and LPS did not reveal any significant changes between parent and resistant strains. The hydrophobicity of the cells increased as the cells were passaged and became less. susceptible. An active efflux system was the most likely mechanism of resistance in all strains tested and a fab1 mutation was associated with E. coli 0157 resistant to TLN isolates. In all isolates investigated the resistance was stable for over 30 passages in biocide-free media. A high degree of cross-resistance was obtained in TLN-resjstant Escherichia coli 0157 strains, which repeatedly exerted decreased susceptibility to various antimicrobials, including chloramphenicol, erythromycin, imipenem, tetracycline and trimethoprirn:, as well as to various biocides. The results of this laboratory-based investigation suggest that it is possible for microorganisms to become resistant to biocides when repeatedly exposed to sublethal concentrations. This may be especially the case in the domestic environment where administration of biocides is poorly controlled. Eventually it could lead to the undesirable situation of resident strains becoming resistant to disinfection and cross resistant to other antimicrobials.

Deformation of sand in plane strain and oxisymmetric compression

Small scale laboratory experiments, in which the specimen is considered to represent an element of soil in the soil mass, are essential to the evolution of fundamental theories of mechanical behaviour. In this thesis, plane strain and axisymmetric compression tests, performed on a fine sand, are reported and the results are compared with various theoretical predictions. A new apparatus is described in which cuboidal samples can be tested in either axisymmetric compression or plane strain. The plane strain condition is simulated either by rigid side platens, in the conventional manner, or by flexible side platens which also measure the intermediate principal stress. Close control of the initial porosity of the specimens is achieved by a vibratory method of sample preparation. The strength of sand is higher in plane strain than in axisymmetric compression, and the strains required to mobilize peak strength are much smaller. The difference between plane strain and axisymmetric compression behaviour is attributed to the restrictions on particle movement enforced by the plane strain condition; this results in an increase in the frictional component of shear strength. The stress conditions at failure in plane strain, including the intermediate principal stress, are accurately predicted by a theory based on the stress- dilatancy interpretation of Mohr's circles. Detailed observations of rupture modes are presented and measured rupture plane inclinations are predicted by the stress-dilatancy theory. Although good correlation with the stress-dilatancy theory is obtained during virgin loading, in both axisymmetric compression and plane strain, the stress-dilatancy rule is only obeyed during reloading if the specimen has been unloaded to approximate ambient stress conditions. The shape of the stress-strain curves during pre-peak deformation, in both plane strain and axisymmetric compression, is accurately described bv a combined parabolic-hyperbolic specification.

Genotypic and antimicrobial characterisation of Propionibacterium acnes isolates from surgically excised lumbar disc herniations

The anaerobic skin commensal Propionibacterium acnes is an underestimated cause of human infections and clinical conditions. Previous studies have suggested a role for the bacterium in lumbar disc herniation and infection. To further investigate this, five biopsy samples were surgically excised from each of 64 patients with lumbar disc herniation. P. acnes and other bacteria were detected by anaerobic culture, followed by biochemical and PCR-based identification. In total, 24/64 (38%) patients had evidence of P. acnes in their excised herniated disc tissue. Using recA and mAb typing methods, 52% of the isolates were type II (50% of culture-positive patients), while type IA strains accounted for 28% of isolates (42% patients). Type III (11% isolates; 21% patients) and type IB strains (9% isolates; 17% patients) were detected less frequently. The MIC values for all isolates were lowest for amoxicillin, ciprofloxacin, erythromycin, rifampicin, tetracycline, and vancomycin (≤1mg/L). The MIC for fusidic acid was 1-2 mg/L. The MIC for trimethoprim and gentamicin was 2 to ≥4 mg/L. The demonstration that type II and III strains, which are not frequently recovered from skin, predominated within our isolate collection (63%) suggests that the role of P. acnes in lumbar disc herniation should not be readily dismissed. © 2013 Jess Rollason et al.

A new phylogenetic group of Propionibacterium acnes

Immunofluorescence microscopy-based identification of presumptive Propionibacterium acnes isolates, using the P. acnes-specific mAb QUBPa3, revealed five organisms with an atypical cellular morphology. Unlike the coryneform morphology seen with P. acnes types I and II, these isolates exhibited long slender filaments (which formed large tangled aggregates) not previously described in P. acnes. No reaction with mAbs that label P. acnes types IA (QUBPa1) and II (QUBPa2) was observed. Nucleotide sequencing of the 16S rRNA gene (1484 bp) revealed the isolates to have between 99.8 and 99.9 % identity to the 16S rRNA gene of the P. acnes type IA, IB and II strains NCTC 737, KPA171202 and NCTC 10390, respectively. Analysis of the recA housekeeping gene (1047 bp) did reveal, however, a greater number of conserved nucleotide polymorphisms between the sequences from these isolates and those from NCTC 737 (98.9 % identity), KPA171202 (98.9 % identity) and NCTC 10390 (99.1 % identity). Phylogenetic investigations demonstrated that the isolates belong to a novel recA cluster or lineage distinct from P. acnes types I and II. We now propose this new grouping as P. acnes type III. The prevalence and clinical importance of this novel recA lineage amongst isolates of P. acnes remains to be determined.

Characterisation of propionibacterium acnes

Propionibacterium acnes forms part of the normal flora of the skin, oral cavity, large intestine and the external ear. Historically, P. acnes is considered to be of low virulence; however, in recent years it has been found as the aetiological agent in various pathologies including acne vulgaris, endophthalmitis, endocarditis, osteomyelitis, sarcoidosis, prosthetic hip infections and sciatica. It currently remains unclear why this normally harmless commensal can cause infection and contribute to a number of clinically significant conditions. This thesis has sought to investigate the phenotypic, genetic and antigenic properties of P.acnes strains isolated from sciatica patients undergoing microdiscectomy, normal skin, blood cultures, prosthetic hips and acne lesions. Isolates' phenotype was examined by determining their biotype by analytical profile index, antimicrobial susceptibility, virulence factor expression and serotype. A molecular typing method for P.acnes was developed using random amplification of polymorphic DNA (RAPD). Patient serum was used to screen P.acnes strains for antigens expressed in vivo and the chemical composition determined. The serodiagnostic potential and inflammatory properties of identified antigens were assessed. The optimised and reproducible RAPD protocol classified strains into three major clusters and was found to distinguish between the serotypes I and II for a large number of clinical isolates. Molecular typing by RAPD also enabled the identification of a genotype that did not react with the type I or II monoclonal antibodies and these strains may therefore constitute a previously undiscovered subspecies of P.acnes with a genetic background different from the type I and II serotypes. A major cell associated antigen produced by all strains was identified and characterised. A serological assay based on the antigen was used to measure IgG and IgM levels in serum from patients with acne, sciatica and controls. No difference in levels of antibodies was detected. Inflammatory properties of the antigen were measured by exposing murine macrophage-like cells and measuring the release of nitric oxide and tumour necrosis factor-alpha (TNF-α). Only TNF-α was elicited in response to the antigen. The phenotypic, genotypic and antigenic properties of this organism may provide a basis for future studies on P.acnes virulence and provide an insight into its mechanisms of pathogenesis.

The mechanics of ultrasonic tube bending

The technology of precision bending of tubes has recently increased in importance and is widely demanded for many industrial applications. However, whilst attention has been concentrated on automation and increasing the production rate of the bending machines, it seems that with one exception very little work has been done in order to understand and therefore fundamentally improve the bending process. A new development for the process of draw-bending of tubes, in which the supporting mandrel is axially vibrated at an ultrasonic frequency, has been perfected. A research programme was undertaken to study the mechanics of tube• bending under both vibratory and non-vibratory conditions. For this purpose, a conventional tube-bending machine was modified and equipped with an oscillatory system. Thin-walled mild steel tubes of different diameter to thickness ratios were bent to mean bend radii having various values from 1.5 to 2.0 times the tube diameter. It was found that the application of ultrasonic vibration reduces the process forces and that the force reduction increases with increasing the vibration amplitude. A reduction in the bending torque of up to 30 per cent was recorded and a reduction in the maximum tube-wall thinning of about 15 per cent was observed. The friction vector reversal mechanism as well as a reduction in friction account for the changes of the forces and the strains. Monitoring the mandrel friction during bending showed, in some cases, that the axial vibration reverses the mandrel .mean force from tension to compression and, thus, the mandrel is assisting the tube motion instead of resisting it. A theory has been proposed to describe the mechanics of deformation during draw-bending of tubes, which embodies the conditions of both "with" and "without" mandrel axial vibration. A theoretical analysis, based on the equilibrium of forces approach, has been developed in which the basic process parameters were taken into consideration. The stresses, the strains and the bending torque were calculated utilising this new solution, and a specially written computer programme was used to perform the computations. It was shown that the theory is in good agreement with the measured values of the strains under vibratory and non-vibratory conditions. Also, the predicted bending 'torque showed a similar trend to that recorded experimentally.

Anisotropic characterization of crack growth in the tertiary flow of asphalt mixtures in compression

Asphalt mixtures exhibit primary, secondary, and tertiary stages in sequence during a rutting deterioration. Many field asphalt pavements are still in service even when the asphalt layer is in the tertiary stage, and rehabilitation is not performed until a significant amount of rutting accompanied by numerous macrocracks is observed. The objective of this study was to provide a mechanistic method to model the anisotropic cracking of the asphalt mixtures in compression during the tertiary stage of rutting. Laboratory tests including nondestructive and destructive tests were performed to obtain the viscoelastic and viscofracture properties of the asphalt mixtures. Each of the measured axial and radial total strains in the destructive tests were decomposed into elastic, plastic, viscoelastic, viscoplastic, and viscofracture strains using the pseudostrain method in an extended elastic-viscoelastic correspondence principle. The viscofracture strains are caused by the crack growth, which is primarily signaled by the increase of phase angle in the tertiary flow. The viscofracture properties are characterized using the anisotropic damage densities (i.e., the ratio of the lost area caused by cracks to the original total area in orthogonal directions). Using the decomposed axial and radial viscofracture strains, the axial and radial damage densities were determined by using a dissipated pseudostrain energy balance principle and a geometric analysis of the cracks, respectively. Anisotropic pseudo J-integral Paris' laws in terms of damage densities were used to characterize the evolution of the cracks in compression. The material constants in the Paris' law are determined and found to be highly correlated. These tests, analysis, and modeling were performed on different asphalt mixtures with two binders, two air void contents, and three aging periods. Consistent results were obtained; for instance, a stiffer asphalt mixture is demonstrated to have a higher modulus, a lower phase angle, a greater flow number, and a larger n1 value (exponent of Paris' law). The calculation of the orientation of cracks demonstrates that the asphalt mixture with 4% air voids has a brittle fracture and a splitting crack mode, whereas the asphalt mixture with 7% air voids tends to have a ductile fracture and a diagonal sliding crack mode. Cracks of the asphalt mixtures in compression are inclined to propagate along the direction of the external compressive load. © 2014 American Society of Civil Engineers.

Exploring the biological basis for Salmonella persistence in food manufacturing environments

The persistence of Salmonella spp. in low moisture foods is a challenge for the food industry as despite control strategies already in place, notable outbreaks still occur. The aim of this study was to characterise isolates of Salmonella, known to be persistent in the food manufacturing environment, by comparing their microbiological characteristics with a panel of matched clinical and veterinary isolates. The gross morphology of the challenge panel was phenotypically characterised in terms of cellular size, shape and motility. In all the parameters measured, the factory isolates were indistinguishable from the human, clinical and veterinary strains. Further detailed metabolic profiling was undertaken using the biolog Microbial ID system. Multivariate analysis of the metabolic microarray revealed differences in metabolism of the factory isolate of S.Montevideo, based on its upregulated ability to utilise glucose and the sugar alcohol groups. The remainder of the serotype-matched isolates were metabolically indistinguishable. Temperature and humidity are known to influence bacterial survival and through environmental monitoring experimental parameters were defined. The results revealed Salmonella survival on stainless steel was affected by environmental temperatures that may be experienced in a food processing environment; with higher survival rates (D25=35.4) at temperatures at 25°C and lower humidity levels of 15% RH, however a rapid decline in cell count (D10=3.4) with lower temperatures of 10°C and higher humidity of 70% RH. Several resident factories strains survived in higher numbers on stainless steel (D25=29.69) compared to serotype matched clinical and veterinary isolates (D25=22.98). Factory isolates of Salmonella did not show an enhanced growth rate in comparison to serotype matched solates grown in Luria broth, Nutrient broth and M9 minimal media indicating that as an independent factor, growth was unlikely to be a major factor driving Salmonella persistence. Using a live / dead stain coupled with fluorescence microscopy revealed that when no longer culturable, isolates of S.Schwarzengrund entered into a viable nonculturable state. The biofilm forming capacity of the panel was characterised and revealed that all were able to form biofilms. None of the factory isolates showed an enhanced capability to form biofilms in comparison to serotype-matched isolates. In disinfection studies, planktonic cells were more susceptible to disinfectants than cells in biofilm and all the disinfectants tested were successful in reducing bacterial load. Contact time was one of the most important factors for reducing bacterial populations in a biofilm. The genomes of eight strains were sequenced. At the nucleotide and amino acid level the food factory isolates were similar to those of isolates from other environments; no major genomic rearrangements were observed, supporting the conclusions of the phenotypic and metabolic analysis. In conclusion, having investigated a variety of morphological, biochemical and genomic factors, it is unlikely that the persistence of Salmonella in the food manufacturing environment is attributable to a single phenotypic, metabolic or genomic factor. Whilst a combination of microbiological factors may be involved it is also possible that strain persistence in the factory environment is a consequence of failure to apply established hygiene management principles.