Phenotypic and genotypic characterisation of Clostrum Difficile

Clostridium difficile is at present one of the most common nosocomial infections in the developed world. Hypervirulent strains (PCR ribotype 027) of C. difficile which produce enhanced levels of toxins have also been associated with other characteristics such as a greater rate of sporulation and resistance to fluoroquinolones. Infection due to C. difficile PCR ribotype 027 has also been associated with greater rates of morbidity and mortality. The aim of this thesis was to investigate both the phenotypic and genotypic characteristics of two populations of toxigenic clinical isolates of C. difficile which were recovered from two separate hospital trusts within the UK. Phenotypic characterisation of the isolates was undertaken using analytical profile indexes (APIs), minimum inhibitory concentrations(MICs) and S-layer protein typing. In addition to this, isolates were also investigated for the production of a range of extracellular enzymes as potential virulence factors. Genotypic characterisation was performed using a random amplification of polymorphic DNA(RAPD) PCR protocol which was fully optimised in this study, and the gold standard method, PCR ribotyping. The discriminatory power of both methods was compared and the similarity between the different isolates also analysed. Associations between the phenotypic and genotypic characteristics and the recovery location of the isolate were then investigated. Extracellular enzyme production and API testing revealed little variation between the isolates; with S-layer typing demonstrating low discrimination. Minimum inhibitory concentrations did not identify any resistance towards either vancomycin or metronidazole; there were however significant differences in the distribution of antibiogram profiles of isolates recovered from the two different trusts. The RAPD PCR protocol was successfully optimised and alongside PCR ribotyping, effectively typed all of the clinical isolates and also identified differences in the number of types defined between the two locations. Both PCR ribotyping and RAPD demonstrated similar discriminatory power; however, the two genotyping methods did not generate amplicons that mapped directly onto each other and therefore clearly characterised isolates based on different genomic markers. The RAPD protocol also identified different subtypes within PCR ribotypes, therefore demonstrating that all isolates defined as a particular PCR ribotype were not the same strain. No associations could be demonstrated between the phenotypic and genotypic characteristics observed; however, the location from which an isolate was recovered did appear to influence antibiotic resistance and genotypic characteristics. The phenotypic and genotypic characteristics observed amongst the C. difficile isolates in this study, may provide a basis for the identification of further targets which may be potentially incorporated into future methods for the characterisation of C. difficile isolates.

A comparative study of hospital management in Great Britain and Brazil : cost information use

In Great Britain and Brazil healthcare is free at the point of delivery and based study only on citizenship. However, the British NHS is fifty-five years old and has undergone extensive reforms. The Brazilian SUS is barely fifteen years old. This research investigated the middle management mediation role within hospitals comparing managerial planning and control using cost information in Great Britain and Brazil. This investigation was conducted in two stages entailing quantitative and qualitative techniques. The first stage was a survey involving managers of 26 NHS Trusts in Great Britain and 22 public hospitals in Brazil. The second stage consisted of interviews, 10 in Great Britain and 22 in Brazil, conducted in four selected hospitals, two in each country. This research builds on the literature by investigating the interaction of contingency theory and modes of governance in a cross-national study in terms of public hospitals. It further builds on the existing literature by measuring managerial dimensions related to cost information usefulness. The project unveils the practice involved in planning and control processes. It highlights important elements such as the use of predictive models and uncertainty reduction when planning. It uncovers the different mechanisms employed on control processes. It also depicts that planning and control within British hospitals are structured procedures and guided by overall goals. In contrast, planning and control processes in Brazilian hospitals are accidental, involving more ad hoc actions and a profusion of goals. The clinicians in British hospitals have been integrated into the management hierarchy. Their use of cost information in planning and control processes reflects this integration. However, in Brazil, clinicians have been shown to operate more independently and make little use of cost information but the potential signalled for cost information use is seen to be even greater than that of their British counterparts.

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.

The political shaping of energy technology:combined heat and power in Britain

There has been negligible adoption of combined heat and power (CHP) for district heating (DH) in Britain, despite continued advocacy. This thesis constructs an account of the treatment of the option, and devises a framework for explanation. Analysis of technological development and adoption, it is argued, should be similar to that of other social processes, and be subject to the same requirements and criticisms. They will, however, show features peculiar to the institutions developing and selecting technologies, their relation to different social groups, and the forms of knowledge in and about technology. Conventional approaches - organisation and interorganisation theories, and analyses of policy-making - give useful insights but have common limitations. Elements of an analytical framework situating detailed issues and outcomes in a structured historical context are derived from convergent radical critiques. Thus activity on CHP/DH is essentially shaped by the development and relations of energy sector institutions: central and local government, nationalised industries and particularly the electricity industry. Analysis of them is related to the specific character of the British state. A few CHP and DH installations were tried before 1940. During postwar reconstruction, extensive plans for several cities were abandoned or curtailed. In the 1960s and 70s, many small non-CHP DH schemes were installed on housing estates. From the mid-70s, the national potential of CHP/DH has been reappraised, with widespread support and favourable evaluations, but little practical progress. Significant CHP/DH adoption is shown to have been systematically excluded ultimately by the structure of energy provision; centralised production interests dominate and co-ordination is weak. Marginal economics and political commitment have allowed limited development in exceptional circumstances. Periods of upheaval provided greater opportunity and incentive for CHP/DH but restructuring eventually obstructed it. Explanation of these outcomes is shown to require analysis at several levels, from broad context to detailed action.

Paediatric 'care closer to home':stake-holder views and barriers to implementation

In this study we explore the views of NHS stakeholders on providing paediatric ‘care closer to home’ (CCTH), in community-based outpatient clinics delivered by consultants. Design: Semi-structured interviews and thematic framework analysis. Setting: UK specialist children's hospital and surrounding primary care trusts. Participants: 37 NHS stakeholders including healthcare professionals, managers, commissioners and executive team members. Results: Participants acknowledged that outreach clinics would involve a change in traditional ways of working and that the physical setting of the clinic would influence aspects of professional practice. Different models of CCTH were discussed, as were alternatives for improving access to specialist care. Participants supported CCTH as a good principle for paediatric outpatient services; however the challenges of setting up and maintaining community clinics meant they questioned how far it could be achieved in practice. Conclusions: The place of service delivery is both an issue of physical location and professional identity. Policy initiatives which ignore assumptions about place, power and identity are likely to meet with limited success.

The association between presenteeism and engagement of National Health Service staff

Objective: Although several studies have demonstrated a relationship between staff engagement and health and wellbeing, none has analysed the association with presenteeism in the National Health Service (NHS) context. Our aim is to determine whether there is a relationship between presenteeism and staff engagement. Methods: A hierarchical logistic multilevel modelling of cross-sectional data from the NHS staff survey (2009) was conducted. We controlled for a range of demographic and socioeconomic background variables, including ethnic group, gender, age and occupational group. The sample was 156,951 respondents across all 390 English NHS trusts, each providing a random sample of employees. Engagement was measured using three facets: motivation, advocacy and involvement, which were also used in a composite score. Results: Therewas a low-to-moderate negative correlation between presenteeismand staff engagement: odds ratio 0.42 (95% confidence interval [CI] 0.42-0.43) for overall staff engagement and 0.53 (95% CI 0.52-0.54) for staff advocacy of the trust; 0.53 (95% CI 0.52-0.54) for motivation and 0.50 (95% CI 0.49-0.51) for involvement. Conclusions: Putting pressure on health-care staff to come to work when unwell is associated with poorer staff engagement with their jobs. © The Royal Society of Medicine Press Ltd 2011.

Co-owners and severance - determining beneficial entitlement after Stack

The article seeks to examine the effect of a severance of a joint beneficial title following the House of Lords' ruling in Stack v Dowden [2007] 2 AC 432. If, under Stack, the parties' beneficial interests fall to be treated as identical to their legal interests (in effect, giving rise to a joint tenancy both at law and in equity), how does the mechanism of severance of a joint beneficial tenancy actually operate so as to give rise to separate and unequal shares where the parties' common intention has changed by virtue of post-acquisition events? The question is examined by reference to an ambulatory and new constructive trust, as well as where the parties have entered into an express declaration of trust of their beneficial interests.

Orders for sale:the creditor and the family home : part one

This, the first part of a two-part article on the discretionary powers of the courts to order a sale of the family home at the request of a secured creditor, considers whether the enactment of the Trusts of Land and Appointment of Trustees Act 1996 s.15 has led judicial decision making to favour the interests of the co-owner of the home. Reviews cases heard since the coming into force of the Act, looking at the factors taken into account when balancing the interests of the creditor and debtor, including the continued need to have a family home, the availability of other assets to pay off the debt, the size of the debt and the likelihood of repayment.

Patients' and health professionals' views on primary care for people with serious mental illness:focus group study

Objective: To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design: Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting: Six primary care trusts in the West Midlands. Participants: Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results: Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and preferred to consult their own GP, who listened and was willing to learn, rather than be referred to a different GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms ("acted up") to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions: Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness.

Co-ownership and severance after Stack

Considers if and how a beneficial joint tenancy arising under the presumption of joint beneficial entitlement following the Supreme Court rulings in Stack v Dowden and Jones v Kernott can come to be severed.

Joint purchasers and the presumption of joint beneficial ownership:a matter of informed choice?

This paper examines the ruling of Jones v Kernott and shows the results of an empirical survey of conveyancing solicitors and their practices where so affected by the ruling. In particular the paper considers how conveyancing practitioners deal with the issue of organising trusts of land and giving advice to clients in relation to the co-purchase of land.

Certainty of subject matter in the law of trusts

This piece argued that the accepted orthodoxy concerning the requirement that each individual piece of property is individually segregated for a valid trust to exist is unsupported by the case law, and that there is nothing wrong in principle or theory with a trust that exists for unsegregated property.