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Background: There is evidence to suggest that the long-term doctor-patient relationship is crucial in the management of chronic illness such as chronic kidney disease. While previous research has focused on patient views of the doctor-patient relationship, research exploring the doctor's experiences of this unique dynamic is lacking, leading to a gap in our understanding. Therefore, an enhanced appreciation of the experience of the doctor is important and could have potential implications for medical training and service organisation., Objectives: In this paper, we report the first known study exploring the experience of consultant nephrologists in the long-term doctor-patient relationship., Participants and Design: Seven male consultant nephrologists (mean age of 48 years) took part in semi-structured interviews, and data were analysed using interpretative phenomenological analysis (IPA)., Results: Three main themes were identified from the analysis: 'Defining my professional identity', 'Relating to the patient' and 'Coping with the job'., Conclusion: Participants had difficulty in defining their role as doctors, discussing themselves as being more than a doctor and comparing themselves with other medical specialties to help them define their identity. Although participants enjoyed forming long-term relationships with patients and the closeness this involved, they discussed the acute scenarios of saving lives as the most rewarding aspect of their job and used coping mechanisms that enabled them to remain detached in the relationship., (© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

To estimate the minimal gene set required to sustain bacterial life in nutritious conditions, we carried out a systematic inactivation of Bacillus subtilis genes. Among approximately 4,100 genes of the organism, only 192 were shown to be indispensable by this or previous work. Another 79 genes were predicted to be essential. The vast majority of essential genes were categorized in relatively few domains of cell metabolism, with about half involved in information processing, one-fifth involved in the synthesis of cell envelope and the determination of cell shape and division, and one-tenth related to cell energetics. Only 4% of essential genes encode unknown functions. Most essential genes are present throughout a wide range of Bacteria, and almost 70% can also be found in Archaea and Eucarya. However, essential genes related to cell envelope, shape, division, and respiration tend to be lost from bacteria with small genomes. Unexpectedly, most genes involved in the Embden-Meyerhof-Parnas pathway are essential. Identification of unknown and unexpected essential genes opens research avenues to better understanding of processes that sustain bacterial life.

The Bacillus subtilis thermosensitive mutant ts-21 bears two C-G-->T-A transitions in the mnaA gene. At the nonpermissive temperature it is characterized by coccoid cell morphology and reduced cell wall phosphate content. MnaA converts UDP-N-acetylglucosamine into UDP-N-acetylmannosamine, a precursor of the teichoic acid linkage unit.

A method is described for measuring the synthesis of poly(glycerol phosphate) [poly(groP)], the major wall teichoic acid (WTA), lipoteichoic acid (LTA) and phospholipid (P-lipid), through fractionation of [2-3H]glycerol ([2-3H]gro)-labelled Bacillus subtilis cells. When cultures of certain temperature-sensitive mutants defective in one of several tag genes, encoding enzymes involved in WTA synthesis, were transferred to the restrictive temperature, the synthesis of WTA underwent a specific, immediate, block, while that of LTA or P-lipid proceeded unimpeded. These results, in addition to confirming the role of tag genes, demonstrated, reciprocally, the specificity of the fractionation procedure used to distinguish label in WTA from that in LTA or P-lipid. Results of analysis of other, less severely affected, tag-deficient mutants, as well as of another genetically unrelated mutant developing comparable morphological phenotypes in non-permissive conditions, are discussed in relation to a possible mechanism generating the latter phenotype. Fractionation of B. subtilis 168 cells labelled either with [2-3H]gro or with [1-14C]N-acetylglucosamine, to which tunicamycin was added at 0.5 microg ml(-1) (the MIC) revealed a specific and marked inhibition of poly(groP) as well as of poly(3-O-beta-D-glucopyranosyl-N-acetylgalactosamine 1-phosphate), the minor WTA. However, for 60 min at least, the syntheses of PG, LTA and P-lipid were barely affected.

Estimates for the overall protein content of the periplasm of Escherichia coli range from 4 to 16% of cellular protein. A cursory examination of known sources of contamination inherent to the methods employed for measurement leads to the conclusion that even the lower value may represent an overestimate of the periplasmic protein in E. coli. The protoplast supernatant fraction (PSF) of Bacillus subtilis defines operationally a potential periplasm, which, after correction for cytoplasmic contamination, yielded, in B. subtilis strains 168 and W23, calculated values of 9 and 3%, respectively, of cell protein as being periplasmic. 26 Among enzymes typically periplasmic in E. coli, at least two, RNases and a 5'-nucleotidase, were located in the B. subtilis periplasm. Compared to other cell fractions, RNase activity in the periplasm was associated with several protein bands forming a unique profile. Samples from all growth phases of cells cultured under phosphate-limitation and phosphate-excess revealed that a major part of both investigated activities was induced by phosphate depletion and located outside the plasma membrane. The current belief that a periplasm containing soluble enzymes does not exist in gram-positive bacteria is examined in light of the absence of an outer membrane permeability barrier, and of a clearly defined electron-transparent zone located between the plasma membrane and the cell wall of B. subtilis. Previous results of studies of protein secretion, and cell wall permeability, are reinterpreted by assuming that the thick charged cell wall of gram-positive bacteria can act as the outer permeability barrier, and as such be the functional equivalent of the outer membrane of gram-negative organisms.

The possibility of there being a periplasm in Bacillus subtilis, in the distinct cell compartment bounded by the cytoplasmic membrane and the thick cell wall, has been investigated quantitatively and qualitatively. Cytoplasmic, membrane, and protoplast supernatant fractions were obtained from protoplasts which were prepared isotonically from cells grown under phosphate limitation. The contents of the protoplast supernatant fraction represent an operational definition of the periplasm. In addition, this cell fraction includes cell wall-bound proteins, exoproteins in transit, and contaminating cytoplasmic proteins arising through leakage from, or lysis of a fraction of, protoplasts. The latter, measured by assay of enzyme markers and by radiolabeled RNA and protein, was found to represent 7.6% of total cell protein, yielding a mean of 9.8% +/- 4.8% for B. subtilis 168 protein considered periplasmic. Qualitatively, after subjection of all cell fractions to polyacrylamide gel electrophoresis, RNase and DNase, zymographs revealed that (i) each cell fraction had a unique profile of nucleases and (ii) multiple species and a major fraction of both nucleases were concentrated in the periplasm. We conclude that the operationally defined periplasmic fraction corresponds closely, both quantitatively and qualitatively, to the contents of the periplasm of Escherichia coli. We discuss evidence that the maintenance of the components of this surface compartment in B. subtilis is compatible with the thick negatively charged cell wall acting as an external permeability barrier.

Assays of CDP-glycerol:poly(glycerophosphate) glycerophosphotransferase (CGPTase) (EC 2.7.8.12) in membranes isolated from Bacillus subtilis 168 wild type and 11 strains bearing conditional lethal thermosensitive mutations in tagB, tagD, or tagF revealed that CGPTase deficiency was associated only with mutant tagF alleles. In vitro, thermosensitivity of CGPTase strongly suggests that the structural gene for this enzyme is tagF. We discuss apparent discrepancies between biochemical evidence favoring a membrane location for TagF and a previous report that suggested a cytoplasmic location based on sequence analysis.

A biochemical analysis was undertaken of thermosensitive mutants of Bacillus subtilis 168 harbouring mutations in several tag genes, involved in the synthesis of the major wall teichoic acid, poly(glycerol phosphate), poly(groP). Incorporation of a pulse of [2-3H]glycerol into whole cells, following shift to the restrictive growth temperature, was used to assess synthesis of this polymer and to seek evidence of accumulation of a specific precursor. The rate of incorporation into poly(groP) was strongly decreased in all mutants; glycerol uptake was diminished by 80% or more for a strain harbouring mutation tagB1 (formerly tag-1) and one bearing tagD11 (formerly tag-11). The pool of CDP-glycerol (CDP-gro), a specific precursor of poly(groP), was increased, relative to the wild-type, for all mutations except tagD11, where the pool of CDP-gro was reduced. Cytoplasmic extracts, assayed at the permissive temperature for glycerol-3-phosphate cytidylyltransferase (gro-PCT), the enzyme synthesizing CDP-gro, revealed wild-type activities for all mutations except tagD11. Gro-PCT activity in the latter strain was 100-fold lower and, unlike that in all other mutant strains, highly thermolabile. This thermosensitivity suggests that tagD encodes gro-PCT. The identification, in a gene encoding a poly(groP)-specific enzyme, of a mutation conferring a thermosensitive growth phenotype renders explicit the conclusion that synthesis of this teichoic acid is essential for the growth of B. subtilis.

The resistance spectrum to bacteriophage phi 3T of different Bacillus subtilis 168/W23 strains hybrid for wall teichoic acids suggested that poly(3-O-beta-D-glucopyranosyl-N-acetylgalactosamine 1-phosphate), a so-called minor teichoic acid of strain 168, forms part of the receptor for this phage, and a serologically related group of phages. A representative sample of 25 mutants specifically resistant to phi 3T, obtained from a mutagenized culture by direct selection, were all found to have a greatly reduced galactosamine content. Relevant mutations in these strains were shown by PBS1 transduction and transformation to belong to two linkage groups; a minority, associated with an atypical colony morphology, were localized between sacA and purA, whereas the majority mapped between gtaB and tagB1 (formerly tag-1), a region containing all known genes involved in the synthesis of the major wall teichoic acid, poly(glycerol phosphate). The former mutations mapped in a new locus, gneA, characterized by a deficiency in UDP-N-acetylglucosamine 4-epimerase, while the latter ones, as well as the previously identified pha-3 (Estrela et al., 1986, Journal of General Microbiology 132, 411-415), map is a locus named gga. They are likely to affect membrane-bound enzymes involved in the synthesis of the galactosamine-containing teichoic acid. A possible biological role of this polymer is discussed.

The steady-state concentration of cell wall turnover products in the medium of Bacillus subtilis 168 growing exponentially on a casein hydrolysate-supplemented medium is equivalent to an overall rate of turnover of less than 10% per generation. After transfer of a steady-labeled culture to nonradioactive medium, the rate of release of labeled turnover products increased exponentially for up to two generations. The rate of turnover finally attained by this culture reached an apparently first-order rate of about 50% per generation. The addition of soluble autolytic activity to growing cultures of a mutant possessing a reduced rate of wall turnover resulted in a marked stimulation in the rate of solubilization of the cell wall fraction. The increased rate of solubilization produced was proportional to the concentration of added enzyme and remained constant until less than 20% of the wall originally present was left. Autolytic activity added under these conditions was bound entirely to wall at least one generation old. The results are interpreted in terms of a model for cell wall growth in which wall two or more generations old covers a total surface area at least four times larger than that occupied at the time of synthesis, forming a shallow outer layer (overlying newer wall) from which all turnover takes place. The model is discussed in relation to previous attempts to determine the pattern of surface expansion in bacilli.

Fifty-six mutants of Bacillus subtilis 168 were selected for resistance to bacteriophages phi 29 or phi 25. The mutations were all linked to previously described teichoic acid markers gtaA, gtaB or gtaC, for the first and last of which, the gene products have previously been identified. Each linkage group was shown to have two distinct phenotypes with respect to phage resistance and cell-wall galactosamine content. Recombination indexes of 0.35, 0.13 and 0.41 for groups A, B and C respectively were consistent with the presence of two average-sized genes in groups A and C. Correlation between genetic and phenotypic differences supported this conclusion and led to the designation of two new markers, gtaD and gtaE. Two- and three-factor transformation crosses suggested the order hisA-gtaB-gtaD-gtaA-tag-1 and gtaC-gtaE-argC. Assays for UDPglucose pyrophosphorylase and phosphoglucomutase activities in soluble extracts of representative mutants revealed that, in contrast to previous findings, the former activity was virtually undetectable in all nine group B mutants examined, suggesting that gtaB is the structural gene of this enzyme. Our results allow us to account for discrepancies with respect to previous reports. The thermosensitive mutation previously designated rodC1 was shown to be 90% cotransformable with tag-1. In view of their extremely similar phenotypes the former mutation was renamed tag-3, and the likely order obtained was gtaA-tag-3-tag-1. This suggests that many mutations associated with deformation of cell shape in B. subtilis are located in the region where teichoic acid genes map.

When soluble autolytic activity was added to growing cultures of a mutant possessing a reduced rate of cell wall turnover, there was a delay of more than one generation before solubilization of new cell wall began, in contrast to the immediate increase in the rate of solubilization of old cell wall. A similar delay was found before turnover of new cell wall occurred in the parent, in agreement with a previous report (Mauck et al., 1971). When sodium lauryl sulfate-inactivated cell walls were prepared, the great bulk of the wall formed a uniformly susceptible substrate to added autolytic activity. The immediate solubilization of new wall eliminates insusceptibility to autolytic enzyme as an explanation for the failure to be turned over. There were, however, major differences in the rate of solubilization of wall of different ages. During solubilization of the initial 30% of the cell wall preparation, wall two generations old was solubilized at least seven times faster than wall one-half a generation old. This result is interpreted in terms of differences in accessibility. The cell wall is seen as consisting of a series of layers, the age of which increases with the distance from the membrane, such that wall newly synthesized on the membrane passes out through the thickness of the cell wall layer during subsequent growth and only becomes susceptible to turnover as it reaches the outer surface, largely in the form of a layer, more than one generation after incorporation.

Three mutants with an autolysin-deficient and flagellaless phenotype (lyt) were genetically analyzed and compared with three thermosensitive flagellaless mutants. In view of the near indistinguishability of their phenotypes, all six mutations were assigned to fla loci. They were distributed into four linkage groups, designated flaA through flaD. flaA and flaB map between pyrD and thyA, flaD maps between aroD and lys, and, in agreement with a previous report, flaC maps near hisA. A locus associated with hypermotility, ifm-3, maps near the latter marker. Introduction of ifm-3 into lyt-1- and flaA4-containing strains led to partial suppression of the nonmotile phenotype. We discuss the possibility that the cellular concentration of autolysins is regulated by the expression of fla genes. Discrepancies with respect to previous mapping of flaA and flaB are accounted for.

A localized region of low DNA sequence homology was revealed in two strains of Bacillus subtilis by a specific 100-fold reduction in transformation by W23 DNA of the tag1 locus, a teichoic acid marker of strain 168. Fifty nine rare recombinants, hybrid at this locus, had all acquired donor-specific phage resistance characters, while losing those specific to the 168 recipient. Chemical analysis of isolated cell walls showed that these modifications are associated with major changes in the wall teichoic acids. Genetic analysis demonstrated that determinants for the ribitol phosphate polymer of strain W23 had been transferred to 168, replacing those for the glycerol phosphate polymer in the recipient. All W23 genes coding for poly(ribitol phosphate) in the hybrids and those specifying anionic wall polymers in strain 168 are clustered near hisA. In addition to tag1, the region exchanged extends just beyond gtaA in some hybrids, whereas in others it may include the more distant gtaB marker, encompassing a region sufficient to contain at least 20 average-sized genes. Surface growth, flagellation, transformability and sporulation all appeared normal in hybrids examined. Recombinants without a major wall teichoic acid from either strain were not found, suggesting that an integral transfer of genes for poly(ribitol phosphate) from W23 had occurred in all hybrids isolated. We interpret these results as indicating an essential role for anionic wall polymers in the growth of B. subtilis.

Continuous as well as pulse-labeling and chase experiments with Bacillus subtilis demonstrated that the cell wall (both peptidoglycan and teichoic acid) is composed of a limited number of blocks which, once completed, segregate during subsequent growth without undergoing any mixing with newly synthesized blocks. This observation suggests that new wall material is inserted in a limited number of zones. Previously reported observations which suggested diffuse intercalation of new wall material are reinterpreted on the basis of our results. Experiments performed on different media showed that the number of segregation units per unit of cell length and thus the density of insertion zones increases with medium richness. This finding suggests analogies between the regulation of cell wall and DNA synthesis.

Low concentrations of glutaraldehyde (0.1% or higher) blocked cellular and wall autolysis. The site of autolytic activity was studied by allowing cell autolysis to proceed for very short periods (0 to 15 min) before addition of glutaraldehyde. Electron microscopy of ultrathin sections showed that the primary site of autolytic activity was the leading edge of the nascent cross wall. The base of the cross wall seemed more resistant than the tip. Evidence supporting the involvement of autolysin activity in continued wall extension and in cell separation as well as in the initiation of new sites of wall extension was obtained. In cells exposed for 10 min to chloramphenicol, wall dissolution was very much slower but occurred at the same cross wall site.

Ten minutes after inhibition of protein synthesis with chloramphenicol (CAP) the ability of cells of Streptococcus faecalis (ATCC 9790) to autolyze decreased to less than 20% of the rate for exponential-phase cells. After threonine exhaustion, the time for a 50% drop in the rate of cellular autolysis was about 20 min. These rapid increases in resistance to cellular autolysis could not be accounted for by: (i) the relatively slow and small overall decrease in susceptibility of isolated cell walls to added autolysin, or (ii) a decreased content of either the active or latent (proteinase activatable) form of the autolysin in the wall fraction. Continued wall synthesis resulted in dilution of preexisting autolysin in the isolated wall fraction. The release of labeled "old" relative to "new" wall from CAP-treated cultures showed that wall synthesis shifted away from the areas of wall previously shown to be associated with wall synthesis (extension) in exponential-phase cells. A corresponding dispersal of active autolysin activity was not observed. By using actinomycin D and CAP, a requirement for ribonucleic acid and protein synthesis early in the recovery of cells from amino acid starvation was demonstrated for the recovery in the ability of cells to autolyze. Evidence was obtained which suggests that a protein is involved in the conversion of latent to active autolysin. During recovery from amino acid starvation, increase in wall synthesis and content of active autolysin was delayed (25 to 35 min), whereas an increase in turbidity and latent enzyme content began within 10 min. After treatment with CAP at 22 or 52 min of recovery, a further increase in levels of both active and latent autolysin was severely inhibited; however, the increase in rate of wall synthesis was indistinguishable from that of an untreated control. This suggests that an increase in rate of wall synthesis does not depend on an increase in level of active autolysin.

A 10-hr starvation of Streptococcus faecalis ATCC 9790 for the amino acids methionine and threonine results in cells which are resistant to autolysis and which contain greatly reduced quantities of both active and latent (proteinase activable) forms of the autolytic enzyme (an N-acetyl-muramide glycanhydrolase). Cell walls were isolated from cells harvested at various times during the recovery from such starvation and were assayed for active and latent forms of the autolysin. Within 10 min of recovery the latent enzyme began to increase. Only after 30 to 60 min did the active enzyme begin to increase; after a similar lag, the cells' proneness to lysis markedly increased. The intracellular localization of both forms of the autolysin was examined, using as an experimental tool the ability of added cell wall to bind autolysin. (14)C-lysine-labeled, inactivated cell walls were added to exponential-phase cells, which were then disrupted, and the mixed wall population was isolated. Measurement of the (14)C release during wall autolysis indicated that the active enzyme in the cells was not available for binding to the added (14)C-labeled walls and was therefore wall-bound in vivo. In contrast, up to 85% of latent autolysin activity was found to have been efficiently bound to the added (14)C walls. The results obtained suggest (i) cellular autolysis is a reflection of the level of active enzyme and not of latent enzyme, and (ii) autolysin is synthesized and mainly located in the cytoplasm as an inactive latent precursor (proenzyme) which is transported to sites on the cell wall associated with wall biosynthesis, where it becomes activated.

Cultures of Streptococcus faecalis ATCC 9790 were starved of threonine for 10 hr and then allowed to reinitiate growth in a fresh complete medium. On regrowth, culture turbidity began to increase within 10 min, but the ability of cells to autolyze did not begin to increase until after 30 min. Ultrastructural studies of regrowth of the initially thick-walled cells showed, at about 30 min, centripetal linear extension of new thin cross wall. This was followed, at about 40 min, by a notching, splitting, and peeling apart of the base of the cross wall. After this, extension of new thin peripheral wall from the nascent cross wall appeared to push old thick wall toward the poles. After the first cell division, asymmetric cells with one initial generation thick-walled pole and one second generation thin-walled pole were seen. After two divisions, thick-walled hemispheres were still seen, suggesting conservation of old wall during this time. A small fraction of the initial cell population exhibited aberrations and difficulties in reinitiating linear wall extension and were useful in the establishment of a model for the reinitiation of linear wall extension.

Cell walls from exponential-phase cultures of Streptococcus faecalis ATCC 9790 autolyzed in dilute buffers. Walls were isolated from cultures grown in the presence of (14)C-lysine for about 10 generations and then on (12)C-lysine for 0.1 to 0.8 of a generation (prelabeled). These walls released (14)C to the soluble fraction more slowly than they lost turbidity during the initial stages of autolysis. Walls isolated from cultures grown in the presence of (14)C-lysine for only the last 0.1 to 0.4 of a generation (postlabeled) released (14)C to the supernatant fluid more rapidly than they lost turbidity. Autolysin in both pre- and postlabeled walls was inactivated, and such walls were then incubated in the presence of unlabeled walls containing active autolysin. The inactivated walls lost their (14)C label only very slowly until autolysis of the unlabeled walls was virtually complete and release of soluble autolysin was expected. When this experiment was done in the presence of trypsin, a fourfold increase in the autolysis rate resulted, but the same pattern of (14)C release was observed. A parallel release of (14)C and loss of turbidity from pre- or postlabeled walls was observed upon trypsin "activation" and by addition of isolated soluble autolysin to inactivated walls. We conclude that the wall-bound autolysin acts first on the more recently synthesized portion of the wall. Trypsin appears to speed wall autolysis by activating additional latent autolysin in situ at sites in the older portion of the wall.

The isolation and some properties of two mutants of Streptococcus faecalis ATCC 9790 (S. faecium) which autolyze at a much slower rate than the wild type are described. Compared with the wild type, mutant E71 autolyzed more slowly, contained less active but more latent autolysin in the isolated wall fraction, and possessed a wall of very similar chemical composition and degree of cross-bridging. Ultrastructural studies of exponential phase cells showed that cells of E71 were on the average slightly longer and had slightly thickened walls compared to the wild type. Mutant E81 autolyzed much more slowly, grew exponentially in long chains (8 to 40 cells compared with mainly diplococci), contained much less active and latent autolysin in the wall, and possessed a wall of very similar chemical composition but with about twice the content of N-terminal groups. Mutant E81 walls were more susceptible to isolated autolysin but possessed an autolysin of the same specificity as the wild type. Ultrastructurally E81 cells were, on the average, significantly longer and had thicker walls than the wild type. Mutant E71 may be partially blocked at either transport of autolysin to the wall or in conversion of latent to active autolysin. The pleitropic effects noted in mutant E81 have been taken to suggest a possible membrane defect and to support the role of the autolysin in cell separation.