Inhibition of Rho Is Required for cAMP-induced Melanoma Cell Differentiation

Up-regulation of the cAMP pathway by forskolin or α-melanocyte stimulating hormone induces melanocyte and melanoma cell differentiation characterized by stimulation of melanin synthesis and dendrite development. Here we show that forskolin-induced dendricity is associated to a disassembly of actin stress fibers. Since Rho controls actin organization, we studied the role of this guanosine triphosphate (GTP)-binding protein in cAMP-induced dendrite formation. Clostridium botulinum C3 exotransferase, which inhibits Rho, mimicked the effect of forskolin in promoting dendricity and stress fiber disruption, while the Escherichia coli toxin cytotoxic necrotizing factor-1 (CNF-1), which activates Rho and the expression of a constitutively active Rho mutant, blocked forskolin-induced dendrite outgrowth. In addition, overexpression of a constitutively active form of the Rho target p160 Rho-kinase (P160ROCK) prevented the dendritogenic effects of cAMP. Our results suggest that inhibition of Rho and of its target p160ROCK are required events for cAMP-induced dendrite outgrowth in B16 cells. Furthermore, we present evidence that Rho is involved in the regulation of melanogenesis. Indeed, Rho inactivation enhanced the cAMP stimulation of tyrosinase gene transcription and protein expression, while Rho constitutive activation impaired these cAMP-induced effects. This reveals that, in addition to controlling dendricity, Rho also participates in the regulation of melanin synthesis by cAMP.

Regulation of the Actin Cytoskeleton by Thrombin in Human Endothelial Cells: Role of Rho Proteins in Endothelial Barrier Function

Endothelial barrier function is regulated at the cellular level by cytoskeletal-dependent anchoring and retracting forces. In the present study we have examined the signal transduction pathways underlying agonist-stimulated reorganization of the actin cytoskeleton in human umbilical vein endothelial cells. Receptor activation by thrombin, or the thrombin receptor (proteinase-activated receptor 1) agonist peptide, leads to an early increase in stress fiber formation followed by cortical actin accumulation and cell rounding. Selective inhibition of thrombin-stimulated signaling systems, including Gi/o (pertussis toxin sensitive), p42/p44, and p38 MAP kinase cascades, Src family kinases, PI-3 kinase, or S6 kinase pathways had no effect on the thrombin response. In contrast, staurosporine and KT5926, an inhibitor of myosin light chain kinase, effectively blocked thrombin-induced cell rounding and retraction. The contribution of Rho to these effects was analyzed by using bacterial toxins that either activate or inhibit the GTPase. Escherichia coli cytotoxic necrotizing factor 1, an activator of Rho, induced the appearance of dense actin cables across cells without perturbing monolayer integrity. Accordingly, lysophosphatidic acid, an activator of Rho-dependent stress fiber formation in fibroblasts, led to reorganization of polymerized actin into stress fibers but failed to induce cell rounding. Inhibition of Rho with Clostridium botulinum exoenzyme C3 fused to the B fragment of diphtheria toxin caused loss of stress fibers with only partial attenuation of thrombin-induced cell rounding. The implication of Rac and Cdc42 was analyzed in transient transfection experiments using either constitutively active (V12) or dominant-interfering (N17) mutants. Expression of RacV12 mimicked the effect of thrombin on cell rounding, and RacN17 blocked the response to thrombin, whereas Cdc42 mutants were without effect. These observations suggest that Rho is involved in the maintenance of endothelial barrier function and Rac participates in cytoskeletal remodeling by thrombin in human umbilical vein endothelial cells.

The Golgi-associated COPI-coated buds and vesicles contain β/γ-actin

It has been shown previously that the morphology and subcellular positioning of the Golgi complex is controlled by actin microfilaments. To further characterize the association between actin microfilaments and the Golgi complex, we have used the Clostridium botulinum toxins C2 and C3, which specifically inhibit actin polymerization and cause depolymerization of F-actin in intact cells by the ADP ribosylation of G-actin monomers and the Rho small GTP-binding protein, respectively. Normal rat kidney cells treated with C2 showed that disruption of the actin and the collapse of the Golgi complex occurred concomitantly. However, when cells were treated with C3, the actin disassembly was observed without any change in the organization of the Golgi complex. The absence of the involvement of Rho was further confirmed by the treatment with lysophosphatidic acid or microinjection with the constitutively activated form of RhoA, both of which induced the stress fiber formation without affecting the Golgi complex. Immunogold electron microscopy in normal rat kidney cells revealed that β- and γ-actin isoforms were found in Golgi-associated COPI-coated buds and vesicles. Taken together, the results suggest that the Rho signaling pathway does not directly regulate Golgi-associated actin microfilaments, and that β- and γ-actins might be involved in the formation and/or transport of Golgi-derived vesicular or tubular intermediates.

Delivery of proteins into living cells by reversible membrane permeabilization with streptolysin-O

The pore-forming toxin streptolysin O (SLO) can be used to reversibly permeabilize adherent and nonadherent cells, allowing delivery of molecules with up to 100 kDa mass to the cytosol. Using FITC-labeled albumin, 105–106 molecules were estimated to be entrapped per cell. Repair of toxin lesions depended on Ca2+-calmodulin and on intact microtubules, but was not sensitive to actin disruption or to inhibition of protein synthesis. Resealed cells were viable for days and retained the capacity to endocytose and to proliferate. The active domains of large clostridial toxins were introduced into three different cell lines. The domains were derived from Clostridium difficile B-toxin and Clostridium sordelli lethal toxin, which glycosylate small G-proteins, and from Clostridium botulinum C2 toxin, which ADP-ribosylates actin. After delivery with SLO, all three toxins disrupted the actin cytoskeleton to cause rounding up of the cells. Glucosylation assays demonstrated that G-proteins Rho and Ras were retained in the permeabilized cells and were modified by the respective toxins. Inactivation of these G-proteins resulted in reduced stimulus-dependent granule secretion, whereas ADP-ribosylation of actin by the C. botulinum C2-toxin resulted in enhanced secretion in cells. The presented method for introducing proteins into living cells should find multifaceted application in cell biology.

Bacterial Cellulose-Binding Domain Modulates in Vitro Elongation of Different Plant Cells1

Recombinant cellulose-binding domain (CBD) derived from the cellulolytic bacterium Clostridium cellulovorans was found to modulate the elongation of different plant cells in vitro. In peach (Prunus persica L.) pollen tubes, maximum elongation was observed at 50 μg mL−1 CBD. Pollen tube staining with calcofluor showed a loss of crystallinity in the tip zone of CBD-treated pollen tubes. At low concentrations CBD enhanced elongation of Arabidopsis roots. At high concentrations CBD dramatically inhibited root elongation in a dose-responsive manner. Maximum effect on root hair elongation was at 100 μg mL−1, whereas root elongation was inhibited at that concentration. CBD was found to compete with xyloglucan for binding to cellulose when CBD was added first to the cellulose, before the addition of xyloglucan. When Acetobacter xylinum L. was used as a model system, CBD was found to increase the rate of cellulose synthase in a dose-responsive manner, up to 5-fold compared with the control. Electron microscopy examination of the cellulose ribbons produced by A. xylinum showed that CBD treatment resulted in a splayed ribbon composed of separate fibrillar subunits, compared with a thin, uniform ribbon in the control.

Caracterização microbiológica, química e presença de poluentes orgânicos em amostras de lodo de esgoto de São Paulo

Objetivou-se com este trabalho avaliar o potencial agrícola do lodo de esgoto produzido no estado de São Paulo, bem como, verificar a possibilidade de interação entre a composição química e a abundância relativa de bactérias no lodo. Foram realizadas coletas de amostra de lodo de esgoto em 19 estações de tratamento de esgoto, em três épocas distintas. Nas amostras provenientes das três épocas foram determinados as concentrações dos 16 hidrocarbonetos policíclicos aromáticos (HPAs) listados como prioritários no monitoramento ambiental pela USEPA (acenafteno, acenaftileno, antraceno, benzo(a)antraceno, benzo(a)pireno, benzo(b)fluoranteno, benzo(ghi)perileno, benzo(k)fluoranteno, criseno, dibenzo(a,h)antraceno, fenantreno, fluoranteno, fluoreno, indeno(1,2,3-cd)pireno, naftaleno e pireno). Nas amostras da segunda época de coleta, além da presença de HPAs, determinou-se as concentrações de poluentes orgânicos emergentes (hormônios, produtos farmacêuticos e produtos de uso industrial), realizou-se a caracterização completa segundo a Resolução CONAMA 375/2006 (umidade, pH, N-Kjeldahl e inorgânico, carbono orgânico, cálcio, potássio, fósforo, magnésio, enxofre, boro, cobre, ferro, níquel, manganês, molibdênio, selênio, zinco, alumínio, arsênio, bário, cádmio, cromo, chumbo, mercúrio e sódio) e a caracterização da comunidade bacteriana através de metodologia independente de cultivo (sequenciamento illumina). Os macronutrientes em maiores concentrações no lodo de esgoto são: N > Ca > S > P > Mg > K. Os elementos inorgânicos Ni e Zn apresentaram concentração superior à máxima permitida para utilização agrícola pela resolução Conama 375/2006 em 1 e 3 amostras, respectivamente. A substância inorgânica que mais limita o enquadramento do lodo de esgoto como adubo orgânico (Instrução Normativa 27/2006) é o Hg. Os compostos benzilparabeno, bisfenol AF (BPAF), ácido perfluorooctanoico (PFOA) e tetrabromobisfenol A (TBBPA) não foram detectados. Por outro lado, cimetidina, metilparabeno, bisfenol A (BPA) e triclocarban foram detectados nas 19 amostras avaliadas. O composto presente em maior concentração é o triclocarban. As concentrações de hidrocarbonetos policíclicos aromáticos são baixas, de acordo com a norma Europeia. Os filos Proteobacteria e Bacteroidetes estão presentes em maior abundância relativa. Existe uma comunidade bacteriana núcleo nas estações de tratamento de esgoto do estado de São Paulo, composta por 81 gêneros, presentes nas 19 ETEs avaliadas, dos quais, os que estão em maior abundância relativa são Treponema, Clostridium, Propionibacterium, Syntrophus e Desulfobulbus. A elevação do pH a valores próximos de 12 reduz a diversidade microbiana. Considerando a abundância relativa e a composição química do lodo de esgoto, as estações podem ser agrupadas em três grupos distintos, sendo que um deles é influenciado principalmente pelos teores de Ca, Zn e Cu, o outro pelos teores de Fe e S e o terceiro grupo que foi influenciado pelos demais fatores avaliados.

Produção de biohidrogênio a partir de soro de leite em AnSBBR com recirculação da fase líquida

O presente estudo investigou a aplicação de dois tipos de AnSBBR (reatores anaeróbio com biofilme e operados em batelada e batelada alimentada sequenciais: com recirculação da fase líquida e com agitação) para produção de biohidrogênio tratando água residuária sintética (a base de soro de leite e lactose, respectivamente). O AnSBBR com recirculação da fase líquida, que foi o estudo principal do presente trabalho, apresentou problemas na produção de hidrogênio utilizando soro de leite como substrato. Algumas alternativas, como adaptação da biomassa com substratos puros de degradação mais fácil, controle do pH em valores muito baixos e diferentes formas de inoculação foram testadas, entretanto, sem obtenção de sucesso. A solução do problema foi obtida ao refrigerar o meio de alimentação a 4ºC para evitar a fermentação no frasco de armazenamento, retirar a ureia e a suplementação de nutrientes, e realizar lavagens periódicas do material suporte para retirada de parte da biomassa. Dessa forma eliminaram-se indícios de produção de H2S por possível ação de bactérias redutoras de sulfato (BRS) e atingiu-se uma produção estável de hidrogênio sem, entretanto, eliminar completamento o metano, que foi produzido em baixas concentrações. Depois de atingida a estabilidade, investigou-se a influência da concentração afluente de substrato, do tempo de enchimento e da temperatura na produção de biohidrogênio no AnSBBR com recirculação da fase líquida tratando soro de leite. O estudo da concentração afluente apresentou um ponto ótimo para a concentração de 5400 mgDQO.L-1, atingindo valores de 0,80 mol H2.mol-1 lactose e de 660 mL H2.L-1.d-1. O estudo do tempo de enchimento apresentou resultados similares para as condições analisadas. Com relação à temperatura, os melhores resultados foram obtidos com a temperatura mais baixa testada de 15ºC (1,12 mol H2.mol lactose-1 e 1080 mL H2.L-1.d-1), sendo que na temperatura mais alta testada (45°C) não ocorreu produção de hidrogênio. Para o AnSBBR com agitação mecânica, que foi um estudado complementar realizado pelo fato da lactose ser o principal complemento do soro de leite, o desempenho do biorreator foi avaliado de acordo com influência conjunta do tempo de ciclo (tC – 2, 3 e 4 h), da concentração afluente (CSTA – 3600-5400 mgDQO.L-1) e da carga orgânica volumétrica aplicada (COAV – 9,3, 12,3, 13,9, 18,5 e 27,8 mgDQO.L-1.d-1). Foram obtidos excelentes resultados: consumos de carboidratos (lactose), com valores médios sempre acima de 90% e uma produção estável de biohidrogênio em todas as condições estudadas, com metano em baixas concentrações apenas na condição de maior COAV. A diminuição do tC apresentou tendência clara de melhora sobre o RMCRC,n (rendimento molar entre hidrogênio produzido e carboidrato removido) apenas para as condições com menor concentração CSTA, havendo uma relação direta entre CSTA, e RMCRC,n em todos os valores de tC, exceto para o tempo de ciclo de 3 h, exatamente onde ocorreu produção de metano. O melhor valor de RMCRC,n obtido na operação com lactose (1,65 mol H2.mol Carboidrato-1) foi superior aos obtidos em outros trabalhos utilizando a mesma configuração de reator e sacarose como substrato. As análises filogenéticas mostraram que a maioria dos clones analisados foi semelhante à Clostridium. Além destes, clones filogeneticamente semelhantes com a Família Lactobacilaceae, especificamente Lactobacillus rhamnosus foram observados em menor porcentagem no reator, assim como clones com sequências semelhantes a Acetobacter indonesiensis.

Ocorrência e remoção dos protozoários patogênicos Giardia spp. e Cryptosporidium spp. em sistemas de tratamento de esgoto sanitário

O propósito do presente estudo foi investigar e monitorar a remoção de cistos de Giardia spp. e oocistos de Cryptosporidium spp. por diferentes processos de uma estação de tratamento de esgoto (ETE) em escala plena, composta basicamente por tratamento preliminar, reator UASB e flotador por ar dissolvido, e verificar a ocorrência desses protozoários no lodo do reator UASB e do flotador. Além disso, avaliou-se a remoção desses parasitos pelo processo de flotação por ar dissolvido em escala de bancada (equipamento Flotateste). Analisou-se a qualidade das amostras a partir de variáveis físicas e químicas, e pela detecção de microrganismos indicadores - E. coli, coliformes totais e Clostridium perfringens. Os métodos de detecção de protozoários se basearam nas etapas de concentração (tripla centrifugação ou filtração em membrana seguida de tripla centrifugação); purificação por separação imunomagnética (IMS); detecção por reação de imunofluorescência direta (RID). As recuperações de cistos variaram de 32,6 a 67,0 % dependendo do método adotado, já para os oocistos as recuperações estiveram na faixa de 5,6 a 12,0 %. Na ETE-Monjolinho foram detectadas significativas quantidades de cistos de Giardia spp. em 100% das amostras de esgoto analisadas, com concentração média de 1,89 x 104 e 2,35 x 102 cistos.L-1 no esgoto bruto e tratado, respectivamente. Já os oocistos de Cryptosporidium spp. foram detectados em 39,0 % das amostras de esgoto, com concentração média de 1,35 x 102 oocistos.L-1 no esgoto bruto e 5,87 oocistos.L-1 em esgoto tratado (após flotador). A remoção global da ETE para remoção de Giardia spp. foi em média 2,03 log. O lodo do reator UASB e lodo do flotador apresentaram altas quantidade de (oo)cistos, constatando-se a tendência desses sistemas em concentrar os (oo)cistos por seus processos físicos. Algumas correlações significativas foram encontradas, como correlação entre a concentração de cistos no lodo e a variável sólidos totais, a concentração de cistos no esgoto bruto e as variáveis cor aparente, DQO total e particulada, e a concentração de cistos no efluente UASB e o microrganismo Clostridium perfringens. Diferentemente do flotador em escala plena, o processo do flotação por ar dissolvido em escala de bancada alcançou elevadas remoções médias de cistos de Giardia spp., entre 2,5 e 2,7 log nas diferentes condições de floculação estudadas.

Molecular characterization of the microbial species that colonize human ileal and colonic mucosa by using 16S rDNA sequence analysis

Aim: The aim of this study was to characterize the bacterial community adhering to the mucosa of the terminal ileum, and proximal and distal colon of the human digestive tract. Methods and Results: Pinch samples of the terminal ileum, proximal and distal colon were taken from a healthy 35-year-old, and a 68-year-old subject with mild diverticulosis. The 16S rDNA genes were amplified using a low number of PCR cycles, cloned, and sequenced. In total, 361 sequences were obtained comprising 70 operational taxonomic units (OTU), with a calculated coverage of 82.6%. Twenty-three per cent of OTU were common to the terminal ileum, proximal colon and distal colon, but 14% OTU were only found in the terminal ileum, and 43% were only associated with the proximal or distal colon. The most frequently represented clones were from the Clostridium group XIVa (24.7%), and the Bacteroidetes (Cytophaga-Flavobacteria-Bacteroides ) cluster (27.7%). Conclusion: Comparison of 16S rDNA clone libraries of the hindgut across mammalian species confirms that the distribution of phylogenetic groups is similar irrespective of the host species. Lesser site-related differences within groups or clusters of organisms, are probable. Significance and Impact: This study provides further evidence of the distribution of the bacteria on the mucosal surfaces of the human hindgut. Data contribute to the benchmarking of the microbial composition of the human digestive tract.

Tetanus in an adult dog originating from a tooth root abscess

A three-and-a-half-year-old entire male Staffordshire Bull Terrier was presented with a cough and difficulty in swallowing. Two days later the dog was re-presented and a diagnosis of tetanus was made. An abscessed canine tooth was extracted and submitted for culture. Clostridium tetani was cultured from the pulp chamber of the tooth. The dog was treated with tetanus antitoxin, antibiotics and supportive care and made a complete recovery.

Structure of a cellulose degrading bacterial community during anaerobic digestion

It is widely accepted that cellulose is the rate-limiting substrate in the anaerobic digestion of organic solid wastes and that cellulose solubilisation is largely mediated by surface attached bacteria. However, little is known about the identity or the ecophysiology of cellulolytic microorganisms from landfills and anaerobic digesters. The aim of this study was to investigate an enriched cellulolytic microbial community from an anaerobic batch reactor. Chemical oxygen demand balancing was used to calculate the cellulose solubilisation rate and the degree of cellulose solubilisation. Fluorescence in situ hybridisation (FISH) was used to assess the relative abundance and physical location of three groups of bacteria belonging to the Clostridium lineage of the Firmicutes that have been implicated as the dominant cellulose degraders in this system. Quantitation of the relative abundance using FISH showed that there were changes in the microbial community structure throughout the digestion. However, comparison of these results to the process data reveals that these changes had no impact on the cellulose solubilisation in the reactor. The rate of cellulose solubilisation was approximately stable for much of the digestion despite changes in the cellulolytic population. The solubilisation rate appears to be most strongly affected by the rate of surface area colonisation and the biofilm architecture with the accepted model of first order kinetics due to surface area limitation applying only when the cellulose particles are fully covered with a thin layer of cells. (c) 2005 Wiley Periodicals, Inc.

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.

Gram-positive infections in patients with end-stage renal disease

Gram-positive microorganisms, specifically coagulase-negative staphylococci are the most common species recovered from clinical culture specimens of patients with end-stage renal disease. The propensity of coagulase-negative staphylococci (CNS) to cause infection in this patient group has been widely debated. However, it is still unclear how this usually avirulent commensal microorganism produces infection that contributes to high rates of morbidity and mortality in patients with end-stage renal disease. The aim of this thesis was to investigate the rate, geographical distribution, molecular and phenotypic mechanisms of Gram-positive microorganisms associated with infection in renal dialysis patients. In addition, it sought to assess the value of early serological diagnosis of dialysis catheter-associated infection and the effect of antimicrobial treatment regimens on the faecal carriage of enteric microorganisms. In this study, the incidence of haemodialysis catheter-associated infection was established with the Meditrend audit tool. This tool was used to assess the infection outcomes of catheter insertion and management procedures until the catheter was explanted. Introduction of a catheter management protocol decreased the incidence of catheter-related infection. Staphylococcal species recovered from episodes of haemodialysis catheter-associated infection and continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis were genotyped by determination of macrorestriction profiles with pulsed-field gel electrophoresis. This highlighted horizontal transfer of microorganisms between different patients and the environment. The phenotypic characteristics of these strains were also investigated to determine characteristics that could be used as markers for dialysis catheter-associated infection. The expression of elastase, lipase and esterase by CNS was significantly associated with infection. A rapid enzyme-linked immunosorbent assay incorporating a novel staphylococcal antigen (lipid S) was used to evaluate the early detection of anti-staphylococcal immunoglobulin gamma in patient sera. The comparison of culture positive and culture negative patients demonstrated a steady state of immune activation in both groups. However anti-lipid S serum antibody titres > 1000 were found to be a predictor of infection. The effect on faecal carriage of vancomycin resistant enterococci (VRE) and Clostridium difficile toxins in patients treated with CAPD when empiric cephalosporin therapy was substituted for piperacillin/tazobactam was investigated. The introduction of piperacillin/tazobactam demonstrated a decrease in the faecal carriage of VRE.

Multiple component patient safety intervention in English hospitals:controlled evaluation of second phase

Objective: To independently evaluate the impact of the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures. Design: A controlled before and after design. Five substudies: survey of staff attitudes; review of case notes from high risk (respiratory) patients in medical wards; review of case notes from surgical patients; indirect evaluation of hand hygiene by measuring hospital use of handwashing materials; measurement of outcomes (adverse events, mortality among high risk patients admitted to medical wards, patients' satisfaction, mortality in intensive care, rates of hospital acquired infection). Setting: NHS hospitals in England. Participants: Nine hospitals participating in SPI2 and nine matched control hospitals. Intervention The SPI2 intervention was similar to the SPI1, with somewhat modified goals, a slightly longer intervention period, and a smaller budget per hospital. Results: One of the scores (organisational climate) showed a significant (P=0.009) difference in rate of change over time, which favoured the control hospitals, though the difference was only 0.07 points on a five point scale. Results of the explicit case note reviews of high risk medical patients showed that certain practices improved over time in both control and SPI2 hospitals (and none deteriorated), but there were no significant differences between control and SPI2 hospitals. Monitoring of vital signs improved across control and SPI2 sites. This temporal effect was significant for monitoring the respiratory rate at both the six hour (adjusted odds ratio 2.1, 99% confidence interval 1.0 to 4.3; P=0.010) and 12 hour (2.4, 1.1 to 5.0; P=0.002) periods after admission. There was no significant effect of SPI for any of the measures of vital signs. Use of a recommended system for scoring the severity of pneumonia improved from 1.9% (1/52) to 21.4% (12/56) of control and from 2.0% (1/50) to 41.7% (25/60) of SPI2 patients. This temporal change was significant (7.3, 1.4 to 37.7; P=0.002), but the difference in difference was not significant (2.1, 0.4 to 11.1; P=0.236). There were no notable or significant changes in the pattern of prescribing errors, either over time or between control and SPI2 hospitals. Two items of medical history taking (exercise tolerance and occupation) showed significant improvement over time, across both control and SPI2 hospitals, but no additional SPI2 effect. The holistic review showed no significant changes in error rates either over time or between control and SPI2 hospitals. The explicit case note review of perioperative care showed that adherence rates for two of the four perioperative standards targeted by SPI2 were already good at baseline, exceeding 94% for antibiotic prophylaxis and 98% for deep vein thrombosis prophylaxis. Intraoperative monitoring of temperature improved over time in both groups, but this was not significant (1.8, 0.4 to 7.6; P=0.279), and there were no additional effects of SPI2. A dramatic rise in consumption of soap and alcohol hand rub was similar in control and SPI2 hospitals (P=0.760 and P=0.889, respectively), as was the corresponding decrease in rates of Clostridium difficile and meticillin resistant Staphylococcus aureus infection (P=0.652 and P=0.693, respectively). Mortality rates of medical patients included in the case note reviews in control hospitals increased from 17.3% (42/243) to 21.4% (24/112), while in SPI2 hospitals they fell from 10.3% (24/233) to 6.1% (7/114) (P=0.043). Fewer than 8% of deaths were classed as avoidable; changes in proportions could not explain the divergence of overall death rates between control and SPI2 hospitals. There was no significant difference in the rate of change in mortality in intensive care. Patients' satisfaction improved in both control and SPI2 hospitals on all dimensions, but again there were no significant changes between the two groups of hospitals. Conclusions: Many aspects of care are already good or improving across the NHS in England, suggesting considerable improvements in quality across the board. These improvements are probably due to contemporaneous policy activities relating to patient safety, including those with features similar to the SPI, and the emergence of professional consensus on some clinical processes. This phenomenon might have attenuated the incremental effect of the SPI, making it difficult to detect. Alternatively, the full impact of the SPI might be observable only in the longer term. The conclusion of this study could have been different if concurrent controls had not been used.

Isolation and characterisation of bacteria associated with flying insects in hospitals, with particualr emphasis on Clostridum difficile

Clostridium difficile is a bacterial healthcare-associated infection, which houseflies Musca domestica may transfer due to their synanthropic nature. The aims of this thesis were to determine the ability of M. domestica to transfer C. difficile mechanically and to collect and identify flying insects in UK hospitals and classify any associated bacteria. M. domestica exposed to independent suspensions of vegetative cells and spores of C. difficile were able to mechanically transfer the bacteria on to agar for up to 4 hours following exposure. C. difficile could be recovered from fly excreta for 96hrs and was isolated from the M. domestica alimentary canal. Also confirmed was the carriage of C. difficile by M. domestica larvae, although it was not retained in the pupae or in the adults that subsequently developed. Flying insects were collected from ultra-violet light flytraps in hospitals. Flies (order Diptera) were the most commonly identified. Chironomidae were the most common flies, Calliphora vicina were the most common synanthropic fly and ‘drain flies’ were surprisingly numerous and represent an emerging problem in hospitals. External washings and macerates of flying insects were prepared and inoculated onto a variety of agars and following incubation bacterial colonies identified by biochemical tests. A variety of flying insects, including synanthropic flies (e.g. M. domestica and C. vicina) collected from UK hospitals harboured pathogenic bacteria of different species. Enterobacteriaceae were the group of bacteria most commonly isolated, followed by Bacillus spp, Staphylococci, Clostridia, Streptococci and Micrococcus spp. This study highlights the potential for M. domestica to contribute to environmental persistence and spread of C. difficile in hospitals. Also illustrated is the potential for flying insects to contribute to environmental persistence and spread of other pathogenic bacteria in hospitals and therefore the need to implement pest control as part of infection control strategies.