Enhancing Equity in a Widening Participation Scheme for School Students

OBJECTIVES

The Royal College of Surgeons (RCS) Diversity Review 2021 found that premedical school students from ethnic minority backgrounds were dissuaded from pursuing a surgical career. Gloucestershire is in the bottom 20% of disadvantaged counties; there is no widening participation (WP) scheme in the county. We implemented a fully inclusive WP scheme in Gloucester, with means of accessing virtual and face-to-face work experience, to enhance the equity of work experience.

METHODS

A three-stage project was conducted. Stage 1; two separate virtual Q and A sessions, to allow students to ask questions about life as a doctor. Stage 2; conversation between student and patient held virtually, to gain insight into working as a doctor to help determine whether medicine is the career for them. Stage 3; face-to-face work experience. Distribution sent to all 58 schools (state and private) in the county, targeted at secondary school children.

RESULTS

One hundred twenty-nine people attended the Q and A; 70 feedback responses received. Of the total, 86% female and 56% of ethnic minority background. 26% did not have an immediate family member that attended university, 10% had care-giving responsibilities. Eighty-one percent rated the session >8/10 for usefulness. Twenty-seven undertook the virtual conversation, feedback from 11; 91% female, 45% of ethnic minority background, and 27% did not have an immediate family member that attended university. All rated the session 10/10 for usefulness. 10 attended the face-to-face experience, 50% from an ethnic minority background.

CONCLUSION

The RCS Report identified barriers to aspiring students from less-privileged backgrounds pursuing a medical career. More needs to be done with WP schemes to promote equity. Targeted distribution of WP schemes to all schools, utilization of a variety of means of offering work experience, and accessibility to any school-aged student were aspects of our WP to improve exposure to the medical profession.

159 The Role of Proformas in Improving the Documentation of Surgical Ward Rounds

Introduction

Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council and Royal College of Surgeons have both published guidance on WR documentation.

Method

This was a prospective study aiming to review WR documentation within general surgery at Frimley Park Hospital. 17 WR entries were reviewed using an 18-point checklist. A proforma was created based on published guidance and gaps in reviewed documentation. This was introduced for two months before a repeat review was conducted. A third review was conducted after an additional month to monitor for sustained improvement.

Results

Strengths in the baseline included documentation of WR leads (100%) and plans (100%), legible handwriting (95%), and NEWS score (88%). Common weaknesses were documentation of full observations, anticoagulation (both 6%), and relevant bloods and imaging (both 12%). The two months post-proforma review found improvement in all 18 areas of documentation, with five elements scoring 100%. Documentation of anticoagulation improved from 6% to 94%, relevant bloods from 12% to 82%, and full observations from 6% to 76%. Higher scoring WRs were linked to pre-prepared proformas, with lower scores linked to post-take WRs. The review was repeated after an additional month, showing consistently improved results in all areas.

Conclusions

This project has shown significant and sustainable improvement in WR documentation with the proforma. This project would therefore recommend the continued use of the proforma, and an additional review after the junior doctor change over to show continued sustainability.

73 An Audit Evaluating the Management of Pre-Operative Anaemia in Elective Bowel Resections at Frimley Park Hospital

Introduction

Pre-operative anaemia is common within the surgical population, particularly those scheduled for elective bowel resections. National and local guidelines recommend the treatment of pre-operative anaemia, as it is an independent risk factor for poor post-operative outcomes, including length of stay in hospital.

Method

A retrospective study of all NHS patients over the age of 18 scheduled for an elective bowel resection at Frimley Park Hospital between 1st May-31st October 2019.

Results

85 patients met the inclusion criteria, with 29 recorded as anaemic. Of these patients, 55% (n = 16) received iron replacement, all of which were intravenous and did not include mildly anaemic patients. The median rise in haemoglobin post-infusion was 14g/L, with only one patient achieving a normal haemoglobin. The median length of stay for patients with a normal haemoglobin was six days, which increased to eight for those with anaemia of any severity. A statistically significant relationship was found between severity of anaemia and increased length of stay, particularly in the female population.

Conclusions

Pre-operative anaemia was linked to increased length of stay in hospital. The findings support the intravenous treatment of all severities of anaemia pre-operatively and therefore suggest treating mild anaemia patients, as normalising their haemoglobin will improve outcomes.

Overriding water table control on managed peatland greenhouse gas emissions

Global peatlands store more carbon than is naturally present in the atmosphere^1,2. However, many peatlands are under pressure from drainage-based agriculture, plantation development and fire, with the equivalent of around 3 per cent of all anthropogenic greenhouse gases emitted from drained peatland^3-5. Efforts to curb such emissions are intensifying through the conservation of undrained peatlands and re-wetting of drained systems⁶. Here we report eddy covariance data for carbon dioxide from 16 locations and static chamber measurements for methane from 41 locations in the UK and Ireland. We combine these with published data from sites across all major peatland biomes. We find that the mean annual effective water table depth (WTD_e; that is, the average depth of the aerated peat layer) overrides all other ecosystem- and management-related controls on greenhouse gas fluxes. We estimate that every 10 centimetres of reduction in WTD_e could reduce the net warming impact of CO₂ and CH₄ emissions (100-year global warming potentials) by the equivalent of at least 3 tonnes of CO₂ per hectare per year, until WTD_e is less than 30 centimetres. Raising water levels further would continue to have a net cooling effect until WTD_e is within 10 centimetres of the surface. Our results suggest that greenhouse gas emissions from peatlands drained for agriculture could be greatly reduced without necessarily halting their productive use. Halving WTD_e in all drained agricultural peatlands, for example, could reduce emissions by the equivalent of over 1 per cent of global anthropogenic emissions.

Seasonal fluxes of carbon monoxide from an intensively grazed grassland in Scotland

Fluxes of carbon monoxide (CO) were measured using a fast-response quantum cascade laser absorption spectrometer and the eddy covariance method at a long-term intensively grazed grassland in southern Scotland. Measurements lasted 20 months from April 2016 to November 2017, during which normal agricultural activities continued. Observed fluxes followed a regular diurnal cycle, peaking at midday and returning to values near zero during the night, with occasional uptake observed. CO fluxes correlated well with the meteorological variables of solar radiation, soil temperature and soil moisture content. Using a general additive model (GAM) we were able to gap fill CO fluxes and estimate annual fluxes of 0.38 ± 0.046 and 0.35 ± 0.045 g C m^-2 y^-1g C m^-2 y^-1 for 2016 and 2017, respectively. If the CO fluxes reported in this study are representative of UK grasslands, then national annual emissions could be expected to be in the order of 61.91 (54.3-69.5) Gg, which equates to 3.8% (3.4-4.3%) of the current national inventory total.

N-fixation in legumes--An assessment of the potential threat posed by ozone pollution

The growth, development and functioning of legumes are often significantly affected by exposure to tropospheric ozone (O3) pollution. However, surprisingly little is known about how leguminous Nitrogen (N) fixation responds to ozone, with a scarcity of studies addressing this question in detail. In the last decade, ozone impacts on N-fixation in soybean, cowpea, mung bean, peanut and clover have been shown for concentrations which are now commonly recorded in ambient air or are likely to occur in the near future. We provide a synthesis of the existing literature addressing this issue, and also explore the effects that may occur on an agroecosystem scale by predicting reductions in Trifolium (clovers) root nodule biomass in United Kingdom (UK) pasture based on ozone concentration data for a "high" (2006) and "average" ozone year (2008). Median 8% and 5% reductions in clover root nodule biomass in pasture across the UK were predicted for 2006 and 2008 respectively. Seasonal exposure to elevated ozone, or short-term acute concentrations >100 ppb, are sufficient to reduce N-fixation and/or impact nodulation, in a range of globally-important legumes. However, an increasing global burden of CO2, the use of artificial fertiliser, and reactive N-pollution may partially mitigate impacts of ozone on N-fixation.

Plasma CRP levels in premenopausal women with major depression: a 12-month controlled study

C-reactive protein (CRP), an inflammatory marker of cardiovascular risk, is often elevated in major depressive disorder (MDD). The magnitude and consistency of this elevation have not been previously characterized in premenopausal women with MDD. The aim of the study was to prospectively assess plasma CRP levels, body composition, endocrine and metabolic parameters, and depressive status in premenopausal women with MDD (n=77) and controls (n=41), aged 21 to 45. Women were enrolled in a 12-month, controlled study of bone turnover, the P.O.W.E.R. ( Premenopausal, Osteoporosis, Women, Al Endronate, Dep Ression) Study. Blood samples were taken at Baseline, Month 6, and Month 12. Most subjects with MDD were in clinical remission. These women tended to have consistently higher CRP levels than controls over 12 months (p=0.077). BMI was positively related to log[CRP] in women with MDD only. Nine women with MDD had CRP levels greater than 10 mg/l, a value associated with a very high cardiovascular risk. This subset was obese and had significantly higher triglycerides, total cholesterol, LDL-cholesterol, fasting insulin, and HOMA-IR than the rest of women with MDD. The variations in CRP levels over time were high (intra- and inter-individual coefficients of variations of approximately 30-50% and approximately 70-140%, respectively). No control had CRP levels greater than 10 mg/l. Depression was associated with increased plasma CRP in women with MDD. The clinical significance of abnormal plasma CRP for cardiovascular risk needs to be assessed in large prospective studies of women with depression.

C-reactive protein concentrations pre- and post-transfusion

In a prospective study, serum C-reactive protein (CRP) levels were analysed before and after 18 transfusional episodes, using a fluorescence polarization immunoassay. Only patients with a stable CRP value for two consecutive days before transfusion were assessed. Although small rises in CRP concentrations occurred following 55.6% of transfusions, there was no statistically significant difference between pre- and post-transfusion CRP values, and these increases also failed to reach clinical significance. An increase in CRP post-transfusion of greater than 100 mg/l occurred on only one occasion, and was more likely to be due to underlying infection.

Multiple teeth showing invasive cervical resorption - an entity with little known histologic features

Invasive cervical resorption is a relatively uncommon form of external root resorption, characterized by resorption of the cervical region of the root. There is progressive loss of cementum and dentine with replacement by fibrovascular tissue derived from the periodontal ligament, with deposition of cementum-like hard tissue. In most cases, a single tooth is involved. We report a case of invasive cervical resorption that resulted in loss of multiple teeth from two different quadrants. The case highlights the diagnostic difficulty that may arise in this uncommon lesion, the pathologic features of which may be mistaken for a fibro-osseous lesion or a low-grade sarcoma.

Ammonia emission and deposition in Scotland and its potential environmental impacts

The main source of atmospheric ammonia (NH₃) in Scotland is livestock agriculture, which accounts for 85% of emissions. The local magnitude of emissions therefore depends on livestock density, type, and management, with major differences occurring in various parts of Scotland. Local differences in agricultural activities therefore result in a wide range of NH₃ emissions, ranging from less than 0.2 kg N ha⁻¹ year⁻¹ in remote areas of the Scottish Highlands to over 100 kg N ha⁻¹ year⁻¹ in areas with intensive poultry farming. Scotland can be divided loosely into upland and lowland areas, with NH₃ emission being less than and more than 5 kg N ha⁻¹ year⁻¹, respectively.Many semi-natural ecosystems in Scotland are vulnerable to nitrogen deposition, including bogs, moorlands, and the woodland ground flora. Because NH₃ emissions occur in the rural environment, the local deposition to sensitive ecosystems may be large, making it essential to assess the spatial distribution of NH₃ emissions and deposition. A spatial model is applied here to map NH₃ emissions and these estimates are applied in atmospheric dispersion and deposition models to estimate atmospheric concentrations of NH₃ and NH₄⁺, dry deposition of NH₃, and wet deposition of NHx. Although there is a high level of local variability, modelled NH₃ concentrations show good agreement with the National Ammonia Monitoring Network, while wet deposition is largest at high altitude sites in the south and west of Scotland. Comparison of the modelled NH_x deposition fields with estimated thresholds for environmental effects (“critical loads”) shows that thresholds are exceeded across most of lowland Scotland and the Southern Uplands. Only in the cleanest parts of the north and west is nitrogen deposition not a cause for concern. Given that the most intense effects occur within a few kilometres of sources, it is suggested that local spatial abatement policies would be a useful complement to traditional policies that mitigate environmental effects based on emission reduction technologies.

An ozone budget for the UK: using measurements from the national ozone monitoring network; measured and modelled meteorological data, and a 'big-leaf' resistance analogy model of dry deposition

Data from the UK national air-quality monitoring network are used to calculate an annual mass budget for ozone (O3) production and loss in the UK boundary layer during 1996. Monthly losses by dry deposition are quantified from 1 km x 1 km scale maps of O(3) concentration and O(3) deposition velocities based on a big-leaf resistance analogy. The quantity of O(3) deposition varies from approximately 50 Gg-O(3) month(-1) in the winter to over 200 Gg-O(3) month(-1) in the summer when vegetation is actively absorbing O(3). The net O(3) production or loss in the UK boundary layer is found by selecting days when the UK is receiving "clean" Atlantic air from the SW to NW. In these conditions, the difference in O(3) concentration observed at Mace Head and a rural site on the east coast of the UK indicates the net O(3) production or loss within the UK boundary layer. A simple box model is then used to convert the concentration difference into a mass. The final budget shows that for most of the year the UK is a net sink for O(3) (-25 to -800 Gg-O(3) month(-1)) with production only exceeding losses in the photochemically active summer months (+45 Gg-O(3) month(-1)).

A home program of rehabilitation for moderately severe traumatic brain injury patients. The DVHIP Study Group

We have recently reported the results of a prospective controlled randomized trial comparing home versus inpatient cognitive rehabilitation for patients with moderate to severe head injury. That study showed no overall difference in outcomes between the two groups.(1) In this article, we provide further details of the home program arm of the study. All patients in the home program received medical treatment as needed, a multidisciplinary in-hospital evaluation, and TBI counseling before entering the eight-week home program, which then included guidance on home activities, as well as weekly telephone calls from a psychiatric nurse.

Modelling photochemical oxidant formation, transport, deposition and exposure of terrestrial ecosystems

The chemical processes responsible for production of photochemical oxidants within the troposphere have been the subject of laboratory and field study throughout the last three decades. During the same period, models to simulate the atmospheric chemistry, transport and deposition of ozone (O(3)) from individual urban sources and from regions have been developed. The models differ greatly in the complexity of chemical schemes, in the underlying meteorology and in spatial and temporal resolution. Input information from land use, spatial and temporally disaggregated emission inventories and meteorology have all improved considerably in recent years and are not fully implemented in current models. The development of control strategies in both North America and Europe to close the gaps between current exceedances of environmental limits, guide values, critical levels or loads and full compliance with these limits provides the focus for policy makers and the support agencies for the research. The models represent the only method of testing a range of control options in advance of implementation. This paper describes currently applied models of photochemical oxidant production and transport at global and regional scales and their ability to simulate individual episodes as well as photochemical oxidant climatology. The success of current models in quantifying the exposure of terrestrial surfaces and the population to potentially damaging O(3) concentrations (and dose) is examined. The analysis shows the degree to which the underlying processes and their application within the models limit the quality of the model products.

Women's reasons for and barriers to seeking care for breast cancer symptoms

Of note, these findings are based on women who did seek care for symptoms, rather than those who did not. However, the sample does include late care seekers; 23% of participants sought care after 3 months, and 3.6% waited more than a year. Delay often is defined as seeking care 3 months after symptoms are noted. Community health workers, such as public health nurses, may be able to document barriers among women who have symptoms but have not sought care. In this sample of predominantly low-income, minimally educated participants, women were motivated to seek care for their breast symptoms to obtain consultations and diagnoses, as well as to deal with their concerns about their symptoms and possible cancer diagnoses. Clinicians can recognize women's need to know the meaning of their symptoms, providing clarification as soon as possible and reassurance as appropriate. Clinicians and families can affirm that making time for women's symptom evaluations is a priority. Knowing that women's common barriers to accessing the health care system involve financial, time, and logistical considerations can direct health care administrators' agendas. Administrators, clinicians, and women can work for changes in health policies to assure universal coverage for preventive services for all women.

Integrating outcomes measurement into clinical practice improvement across the continuum of care: a disease-specific episode of care model

This article describes a model for incorporating outcomes measurement into a comprehensive, continuum-wide clinical practice improvement program developed at Lovelace Health Systems (Albuquerque, N.M.). Created in 1993, the Lovelace Episode of Care Program currently includes nine disease-specific multidisciplinary teams that are working to improve care by addressing such issues as severity, appropriateness, efficiency, continuous quality improvement indicators, practice guidelines, care maps, and outcomes. Key features and advantages of the model are discussed, as well as implementation issues, successes, lessons learned, program restructuring and improvement, and applicability of the framework across diseases and health organizations.

Mentoring program guides new hospital trustees. A religious institute ensures trustee orientation is mission and value based

In 1990 the Sisters of Charity began offering a mentoring program to ensure that sisters who serve on boards of its sponsored institutions can fulfill their commitment to effective stewardship. For participating healthcare facilities, the program offers an assurance that their trustees will have a clear direction, common information, and a mission- and value-based orientation process. The new trustees gain a basic understanding of their role and responsibilities as trustees, including the ministerial dimension. Mentors in the program benefit by refreshing their understanding of issues facing trustees. Participants in the mentoring program must meet the criteria for all trustees and demonstrate a special commitment to the congregation's mission and philosophy. The mentors are selected on the basis of their experience, availability, and commitment to the congregation's mission and philosophy. After participating in at least one board meeting, the new trustees, along with their mentors, attend an orientation seminar that focuses on sponsorship's history, purposes, principles, and policies and the system's services, roles, and functions. A second seminar is held nine months later for evaluation and follow-up. In addition, the mentors and trustees meet regularly before and/or after each board meeting to discuss pertinent issues, board dynamics, and the new trustee's participation.

Alternative agendas. System priorities for the 1990s will differ from those of the last decade

The Sisters of Charity Health Care Systems (SCHCS) was established in 1979 in response to changes in the U.S. healthcare system and to new needs of sponsors and Catholic healthcare facilities. However, the agenda that SCHCS leaders (and leaders of other systems) set at that time must now give way to an agenda that will address the new challenges and responsibilities facing the Catholic healthcare ministry in the 1990s. In its first decade of existence, SCHCS established and fulfilled a number of goals: It strengthened governance relationships, helped systems and sponsors better identify with local communities, enabled facilities to steward resources more effectively, and facilitated members' understanding of mission and sponsorship values. In the 1990s, however, systems will have to create more opportunities for regional, collaborative, and networking relationships among member facilities and between members and non-members. To achieve this, they will have to reevaluate their structures, find ways to faciliatate collaboration, make resources available to institutions outside the system, and develop an overall philosophy that enhances both the fiscal and spiritual well-being of member facilities.

Revitalizing the ministry

The twentieth century's last decade presents religious institutes with a golden opportunity to confront the dilemmas surrounding sponsorship. Sponsors can develop a number of strategies to allay current anxieties and to transform potential crises into advantages. One is to revitalize the corporate mission by basing it on professed values rather than on existing structures. Institutes can also articulate their mission by building networks that encourage cooperation between those involved in traditional services and those in alternative services. Strengthening collaboration with the laity is also critical. Sponsorship forums are one way to promote mutual understanding and reflection. In addition, involving lay leaders in planning and decision making will broaden their understanding of issues that affect the healthcare institution. Finally, with the laity assuming a greater share of responsibility in Catholic healthcare, many institutes will have to develop strategies that allow them to "let go." The process will require inner transformation. Recognizing the institute's contribution to the development of the Catholic healthcare ministry can help members accept the need for change. Actively planning for the changes will also help members cope with them.

United they thrive: merger of two healthcare systems

On March 15, 1987, the Sisters of St. Francis of Perpetual Adoration of Colorado Springs and the Sisters of Charity of Cincinnati agreed to consolidate. It marked the culmination of years of building mutual trust and months of intense negotiations. The Sisters of St. Francis realized in 1983 that some major decisions had to be made regarding the future direction of its healthcare ministry because of rapid changes within the healthcare industry and declining numbers of Franciscan sisters working in healthcare. In January 1986 leaders of the two institutes and their healthcare systems sat down for the first time to discuss issues surrounding the collaborative effort and to recommend a list of objectives, including joint ventures in various areas. Other recommendations included the formation of a joint steering council to direct the collaborative effort and the formation of a Colorado Springs Task Force to end the rivalry existing between two local hospitals--one Franciscan-sponsored, the other Charity-sponsored. Additional hurdles included finding an affiliation model that all parties would accept (the one endorsed allows the Sisters of St. Francis to continue to exercise substantial control over the future of its healthcare institutions but gives the Sisters of Charity Health Care System much of the operational control); due diligence reviews of legal and financial documents; canonical review; detailed financial analysis; review of all state and federal regulatory requirements, including antitrust; and educating and preparing members of the Franciscan Healthcare Corporation.

Percutaneous renal ablation in patients with end-stage renal disease: alternative to surgical nephrectomy

Percutaneous transcatheter ablation was performed on 18 kidneys in ten patients with end-stage renal disease (ESRD), who were either on hemodialysis or had undergone renal transplantation, for the following indications: nephrotic syndrome with massive protein loss (seven patients, 13 kidneys), poorly controlled posttransplantation hypertension in the absence of transplant renal artery stenosis (two patients, three kidneys), and diabetic nephropathy with persistent urine leak from ureterocutaneous fistulas following pelvic irradiation (one patient, two kidneys). Desired clinical results were achieved in all cases. Percutaneous renal ablation is an effective alternative to surgery in patients with ESRD who require nephrectomy.

Laboratory diagnosis of urinary tract infection in ambulatory women

We evaluated the accuracy and work load of six different approaches to identifying urinary tract infections in a general microbiology laboratory. Midstream urine (MSU) specimens from 387 ambulatory women were examined for pyuria and were cultured using a dual-plating technique that detects both low (10(2) to 10(4) organisms per milliliter) and high (greater than or equal to 10(5) organisms per milliliter) colony counts. Seventy-four urinary tract infections (defined as greater than or equal to 10(5) organisms per milliliter of MSU or greater than or equal to 10(2) aerobic gram-negative bacilli per milliliter of MSU in symptomatic patients) were identified. Twenty-four (32%) of the infections were characterized by low colony counts and would not have been identified using a 10(5) or greater colony-forming units/mL criterion for infection. Using the presence of pyuria to direct microbiological processing of urine specimens was the most accurate and efficient method of identifying urinary tract infections among voided specimens from ambulatory women, particularly if rapid screening methods for pyuria can be used.

Relationship between pNG2, an Emr plasmid in Corynebacterium diphtheriae, and plasmids in aerobic skin coryneforms

Erythromycin-resistant (Emr) coryneforms from cutaneous lesions and erythromycin-susceptible (Ems) coryneforms from normal skin sites were screened for plasmids. Approximately one-third of the 40 isolates carried one or more plasmids ranging in mass from 2.5 to 36 megadaltons, all exhibiting different restriction enzyme digest patterns. In contrast, only Corynebacterium diphtheriae strains comprising a single cohort of apparently identical Emr, pNG2-carrying isolates have been identified as plasmid carriers. Homology was demonstrated between pNG2 and a number of fragments in restriction enzyme digests of plasmids from both Emr and Ems skin coryneforms under high-stringency conditions. However, none was detected between pNG2 and the genomic or plasmid DNAs of Emr staphylococci or streptococci isolated concurrently with the Emr coryneforms. One coryneform plasmid, pNG34, exhibited extensive homology with pNG2, and many comigrating fragments were observed. Very little relationship was observed between C. diphtheriae and the skin coryneforms when their genomic DNAs were hybridized. The origin and presence of pNG2 in Emr C. diphtheriae is discussed in relation to these findings.

Stoma care is our affair for the senior citizens everywhere

The first reported colostomy was in 1776 and it was a caecostomy, or opening into the caecum. This was the first attempt to surgically help the problem of an imperforate anus. The first stomatherapist was a patient in the Cleveland Clinic, Ohio, U.S.A. Now there are 22 countries in the world with qualified stomatherapists. Stomatherapy was founded in South Africa in 1958 and in England in 1967.

Plasmids in Corynebacterium diphtheriae and diphtheroids mediating erythromycin resistance

Plasmids were isolated from erythromycin-resistant Corynebacterium diphtheriae and skin coryneforms. Six erythromycin-resistant C. diphtheriae strains, isolated from cutaneous lesions, all contained a 9.5-megadalton (Mdal) plasmid. Loss of resistance was associated with the deletion of a 1-Mdal segment from the plasmid or, less frequently, with loss of the plasmid. Two erythromycin-resistant diphtheroids were isolated from similar skin lesions. One contained a 38-Mdal plasmid that was lost in the conversion to erythromycin susceptibiliy. The other diphtheroid contained a 30- and a 14-Mdal plasmid. Erythromycin-susceptible derivatives of this strain were not recovered. Restriction enzyme analysis indicated that the 9.5-Mdal plasmids in the C. diphtheriae strains are very similar, if not identical, and that each of the deleted plasmids has lost the same 1-Mdal segment. However, the restriction patterns of the plasmids in the two diphtheroids are not closely related to each other nor to the plasmids in the C. diphtheriae strains.