[THE IMPACT OF REGULATION AND CENTRAL MANAGEMENT ON PATIENT SAFETY IN ISRAEL].

INTRODUCTION: An adverse event is defined as an unwanted and unexpected occurrence in a medical process that may end in harm to the patient. In the USA the number of deaths due to failures reaches 253,000 per year. In Israel, over 10,000 deaths occur per year due to errors in the medical treatment of hospitalized patients, the third most common cause of death after heart disease and cancer. The main cause of failures in medical diagnosis and treatment is the complexity of the medical profession. A large number of caregivers in different medical disciplines are needed to treat one patient, therefore there are many errors, especially regarding communication between therapists. The Israeli health system has been operating with a budget deficit for many years and an addition of at least NIS 20 billion is needed to bring it to optimal functioning. The number of doctors, nurses, and hospital beds per 1000 inhabitants is significantly less than the average of the OECD countries. When there was a 30% increase in the population of Israel it was necessary to enhance the existing situation, with the addition of 7700 hospital beds, but only 1400 were added. This caused a decrease from 2.1 beds per 1000 residents to 1.8 beds per 1000 residents. There is an urgent need to change the elements of treatment safety in the Ministry of Health's strategic plan. An administration for quality, treatment safety, risk management in medicine, and accreditation should be established which, in addition to the care quality division, will include a safety division with investigation and monitoring units and will prepare strategic improvement plans, and a university-level research institute with researchers, computing, statistics, and information gathering units. The institute will receive all reports of adverse events, results of investigations, inspection committees, control and quality committees, relevant verdicts, and updated literature reviews, for research and systemic learning. Strategic plans will be prepared to prevent failures in diagnosis and medical treatment, leading to a decrease in mortality due to adverse events and the significant expenses involved.

The professional agenda and its effect on the implementation of telemedicine among primary care physicians: A qualitative study.

INTRODUCTION: Studies show that physicians' attitudes are a major influential factor in the degree of implementation of telemedicine and that most of them identify much more opportunities in this type of visit than risks. These findings do not explain the observed decrease in the use of telemedicine in primary care with the decline of the COVID-19 pandemic. The aim of our study was to understand the gap between the attitudes that primary care physicians declare towards telemedicine and the extent to which they use it in practice. METHODS: A qualitative research using a semi-structured phone interview with 33 primary care physicians experienced in telemedicine from Leumit Health Services, a health fund in Israel. A qualitative thematic analysis method was used to extract the main themes from all interviews, and descriptive statistical tests were used to analyze the demographic variables. RESULTS: The attitude of the physicians depended on the perception of their professional identity and their sense of control over telemedicine implementation. The more established their professional identity and the stronger the support from the organization in the technology integration, the more positive the physician's attitude towards this type of visit. DISCUSSION: Healthcare organizations that wish to improve the use of telemedicine in primary care should understand that this is more than just the implementation of new technology: they must find a way to properly support the profound change that doctors must undergo when defining their new role and professional status.

Crisis management for Patient Safety Officers: lessons learned from the Covid-19 pandemic.

BACKGROUND: There is no consensus for the role definition for Patient Safety Officers (PSOs) in healthcare during pandemics or other crises as opposed to their routine activities. This study aimed to examine the contribution of personality traits and systemic factors on the performance of PSOs during the pandemic, and to compare these variables during the first and third waves of the Covid-19 pandemic in Israel. METHODS: This cross-sectional study invited 117 PSOs to complete a questionnaire addressing their role during the Covid-19 pandemic. The questionnaire included items concerning: Personal and socio-demographic characteristics; Uncertainty; Personal initiative; Burnout; Professional functioning; Patient Safety and Risk Management policies and practices; Organizational functioning; and Personal Involvement in risk management activities. Qualitative data was collected by two open-ended questions. RESULTS: A total of 78 PSOs (67%) completed the questionnaire. The results revealed that many PSOs reduced their involvement in risk management processes or even left their position temporarily in order to return to their primary specialization as clinicians. Only 51.3% and 57.7% reported practicing risk management in the first and third waves, respectively. The three main factors that kept PSOs functioning were managerial support, mobilization of their team, and the belief in the importance of their position. CONCLUSIONS: A crisis generates uncertainty, a plethora of frequent and urgent tasks, and the need to adapt policy to changing circumstances and to the increased risks. The risk manager must be a member of the crisis management team and participate in every important discussion in order to represent essential staff and patient safety issues and ensure that these are fully addressed already in the early stages of planning.

Identification of behavioural changes in reporting adverse events early during COVID-19: An ambulatory care perspective in Israel.

This study examined adverse event reporting centred on three significant dates in the months before the pandemic arrived in Israel. On these dates, broad media coverage exposed citizens and health care providers with indications about the forthcoming pandemic. The current study tracked whether parameters related to reporting adverse medical events provided early indications that a large crisis was unfolding. The method for analysing the data was based on a statistical test called Regression Discontinuity Design, which helped identify parameters related to medical reporting patterns which significantly changed. The examination indicated nurses' reports were unique in relation to others and indicated three phases: (1) upon declaration of the upcoming pandemic, there was a rise in reporting; (2) when the disease was named, there was moderation and maintenance in a steady quantity of reports, and finally, (3) when the first case arrived in Israel, a slight decrease in reporting began. Nurses' behaviours manifested as changes in reporting patterns. In this process of increase, moderation and decrease, it can be concluded that these are three stages that may characterise the beginning of a large event. The research method presented reinforces the need for forming tools by which significant events such as the COVID-19 pandemic can be identified quickly, and aid in proper planning of resources, optimise staffing and maximise utilization of the health systems.

[CONFIDENTIALITY OF ADVERSE EVENTS INVESTIGATIONS - THE PRESENT STATUS AND WHAT IS NEEDED].

INTRODUCTION: The goal of the medical staff is to provide proper, effective and efficient treatment to the patient and to take care of his well-being. An error in medical care that causes a serious outcome or mortality, can be considered negligence when the caregiver did not meet the requirements of a reasonable physician for reasonable care and did not take the necessary precautions in providing the treatment, in light of the information available to him. The perception of punishment and compensation due to harm, caused to a patient as a result of a medical error, changed dramatically over the years. Starting with direct and severe punishment according to Hammurabi laws and ending with the "no fault" approach that is accepted widely in some countries. Following an adverse event that occurred in medical treatment, a process should be conducted in order to draw lessons to reduce the likelihood of recurrence of similar incidents in the future, by answering 4 questions: What happened? How did it happen? Why did it happen? and What should be done to prevent similar incidents in the future? The Patient Rights Act does not suggest conducting a safety investigation but recommends an examination board in cases of negligence or error in treatment. By law, the protocols of the examination board are confidential and can be removed by the court in case the protocol contains evidence of importance that is unlikely to be found in the medical record. Lack of confidentiality may cause medical staff to be reluctant of conducting a safety investigation due to fear of using its findings for a lawsuit or appointing an examination board whose conclusions will be reported to the victim and his family. The "no fault" method overcomes these barriers by enabling a thorough safety investigation and has important professional, economic and social aspects with a direct impact on the quality and safety of treatment. The method expands the accessibility of victims to compensation, reduces the number of claims and the burden on the courts. Among additional benefits are transparency and consistency in decisions, promoting patient safety due to physicians' willingness to report failures, reduction in "defensive medicine" and spending in the health care system.

[SAFETY ROUNDS IN CLALIT SMILE CLINICS (CLALIT HEALTHCARE SERVICES) AS A MEANS FOR PROMOTING PATIENT SAFETY].

INTRODUCTION: There is a serious gap in risk management and patient safety discipline in dentistry compared to the developments in this area in general medicine. Few publications appear in the professional literature and there is a lack of specific considerations from the regulator aimed to regulate this domain in dentistry in Israel and a lack of activity in this field on the national level: conferences, courses and training may serve as a proof of this gap. AIMS: To develop and implement a process and a tool for conducting safety rounds in Clalit Smile dental clinics. METHODS: The process and the tool were developed in accordance with the guidelines of Ministry of Health, analysis of adverse events reported to Clalit Smile in the years 2012-18, in order to pinpoint the specific risk in Clalit Smile operations and adverse event debriefings. The tool that was developed is implemented in an Excel spreadsheet, where the results of the safety rounds are documented and scores are calculated. RESULTS: The safety round team was positively welcomed by the clinics staff, mentioning the value they attribute to this activity. The concept and the structure of the tool enable it to easily identify the weak points, responsible for lowering the scores in the round and to correct them promptly. The range of the scores: 53.5-60% is relatively low, although differences between the clinics were evident and all of the clinics had to improve in: compliance with procedures, medical records, care plans and maintenance of the medical equipment. CONCLUSIONS: The process and the tool proved themselves to be applicable and able to identify risks and systemic shortcomings in Clalit Smile clinics. DISCUSSION: The safety rounds conducted in this study, enabled identification of clinic-specific risks and shortcomings in addition to systemic shortcomings. Wide implementation of the safety rounds in which at least once in two years every clinic will undergo this process, will enable the identification of clinic-specific risks and their prompt correction and systemic shortcomings. This will facilitate the definition of organizational intervention plans aimed at improving patient safety in the entire organization.

Extension to 'combined SNA and LDA methods to understand adverse medical events': Doctor and nurse perspectives.

BACKGROUND: Physicians and nurses are responsible for reporting medical adverse events. Each views these events through a different lens subject to their role-based perceptions and barriers. Physicians typically engage with diagnosis and treatment while nurses primarily care for patients' daily lives and mental well-being. This results in reporting and describing medical adverse events differently. OBJECTIVE: We aimed to compare adverse medical event reports generated by physicians and nurses to better understand the differences and similarities in perspective as well as the nature of adverse medical events using social network analysis (SNA) and latent Dirichlet allocation (LDA). METHODS: The current study examined data from the Maccabi Healthcare Community. Approximately 17,868 records were collected from 2000 to 2017 regarding medical adverse events. Data analysis used SNA and LDA to perform descriptive text analytics and understand underlying phenomenon. RESULTS: A significant difference in harm levels reported by physicians and nurses was discovered. Shared topic keyword lists broken down by physicians and nurses were derived. Overall, communication, lack of attention, and information transfer issues were reported in medical adverse events data. Specialized keywords, more likely to be used by a physician were determined as: repeated prescriptions, diabetes complications, and x-ray examinations. For nurses, the most common special adverse event behavior keywords were vaccine problem, certificates of fitness, death and incapacity, and abnormal dosage. CONCLUSIONS: Communication and inattentiveness appeared most frequently in medical adverse events reports regardless of whether doctors or nurses did the reporting. Findings suggest feedback and information sharing processes could be implemented as a step toward alleviating many issues. Institutional management, healthcare managers and government officials should take actions to decrease medical adverse events, many of which may be preventable.

Combined SNA and LDA methods to understand adverse medical events.

OBJECTIVE: To compare primary medical adverse event keywords from reporters (e.g. physicians and nurses) and harm level perspectives to explore the underlying behaviors of medical adverse events using social network analysis (SNA) and latent Dirichlet allocation (LDA) leading to process improvements. DESIGN: Used SNA methods to explore primary keywords used to describe the medical adverse events reported by physicians and nurses. Used LDA methods to investigate topics used for various harm levels. Combined the SNA and LDA methods to discover common shared topic keywords to better understand underlying behaviors of physicians and nurses in different harm level medical adverse events. SETTING: Maccabi Healthcare Community is the second largest healthcare organization in Israel. DATA: 17,868 medical adverse event data records collected between 2000 and 2017. METHODS: Big data analysis techniques using social network analysis (SNA) and latent Dirichlet allocation (LDA). RESULTS: Shared topic keywords used by both physicians and nurses were determined. The study revealed that communication, information transfer, and inattentiveness were the most common problems reported in the medical adverse events data. CONCLUSIONS: Communication and inattentiveness were the most common problems reported in medical adverse events regardless of healthcare professional reporting or harm levels. Findings suggested that an information-sharing and feedback mechanism should be implemented to eliminate preventable medical adverse events. Healthcare institutions managers and government officials should take targeted actions to decrease these preventable medical adverse events through quality improvement efforts.

A prospective, randomised, placebo-controlled, double-masked, three-armed, multicentre phase II/III trial for the Study of a Topical Treatment of Ischaemic Central Retinal Vein Occlusion to Prevent Neovascular Glaucoma - the STRONG study: study protocol for a randomised controlled trial.

BACKGROUND: Neovascular glaucoma (NVG) is rare, comprising only 3.9% of all glaucoma cases. The most common cause of NVG is ischaemic central retinal vein occlusion (iCRVO). NVG frequently results in blindness and painful end-stage glaucomatous damage leading to the need for enucleation. Currently, there is no preventive therapy for NVG following iCRVO. Rescue treatments have severe drawbacks. Accordingly, there is a great need for preventing the often visually devastating outcomes of NVG. The STRONG study is designed to test whether the topically active anti-angiogenic agent aganirsen is able to inhibit the formation of neovascularisation leading to the development of secondary NVG in eyes with iCRVO. At the same time, STRONG will provide important information on the natural course of iCRVO and NVG in a large and well-characterised cohort of such patients. METHODS/DESIGN: This protocol describes a phase II/III, prospective, randomised, placebo-controlled, double-masked, three-armed multicentre study for the investigation of aganirsen, a new topical treatment for iCRVO in order to prevent NVG. The study will evaluate the efficacy of two different doses of this newly developed antisense oligonucleotide formulated in an eye emulsion to avoid new vessel formation by blocking insulin receptor substrate-1 (IRS)-1. This leads to subsequent down-regulation of both angiogenic as well as proinflammatory growth factors such as vascular endothelial growth factor (VEGF) and tumour necrosis factor (TNF). Eligible patients (n = 333) will be treated with topical aganirsen or placebo for a period of 24 weeks. They will also be invited to participate in substudies involving analysis of gonioscopic images, detection of biomarkers for NVG and risk factors for iCRVO. DISCUSSION: The STRONG study has the potential to offer a new treatment modality for patients suffering from iCRVO with a high risk of developing NVG. The topical administration can reduce patients' burden and risk related to rescue treatment, such as destructive laser treatment or enucleation, but requires a high level of patient compliance. TRIAL REGISTRATION: EudraCT: 2014-000239-18; ClinicalTrials.gov, ID: NCT02947867 . (Registered on 15 October 2016); see also http://strong-nvg.com .

Continuous drug release by sea anemone Nematostella vectensis stinging microcapsules.

Transdermal delivery is an attractive option for drug delivery. Nevertheless, the skin is a tough barrier and only a limited number of drugs can be delivered through it. The most difficult to deliver are hydrophilic drugs. The stinging mechanism of the cnidarians is a sophisticated injection system consisting of microcapsular nematocysts, which utilize built-in high osmotic pressures to inject a submicron tubule that penetrates and delivers their contents to the prey. Here we show, for the first time, that the nematocysts of the starlet sea anemone Nematostella vectensis can be isolated and incorporated into a topical formulation for continuous drug delivery. We demonstrate quantitative delivery of nicotinamide and lidocaine hydrochloride as a function of microcapsular dose or drug exposure. We also show how the released submicron tubules can be exploited as a skin penetration enhancer prior to and independently of drug application. The microcapsules are non-irritant and may offer an attractive alternative for hydrophilic transdermal drug delivery.

Analysis of soluble protein contents from the nematocysts of a model sea anemone sheds light on venom evolution.

The nematocyst is one of the most complex intracellular structures found in nature and is the defining feature of the phylum Cnidaria (sea anemones, corals, jellyfish, and hydroids). This miniature stinging organelle contains and delivers venom into prey and foe yet little is known about its toxic components. In the present study, we identified by tandem mass spectrometry 20 proteins released upon discharge from the nematocyst of the model sea anemone Nematostella vectensis. The availability of genomic and transcriptomic data for this species enabled accurate identification and phylogenetic study of these components. Fourteen of these proteins could not be identified in other animals suggesting that they might be the products of taxonomically restricted genes, a finding which fits well their origin from a taxon-specific organelle. Further, we studied by in situ hybridization the localization of two of the transcripts encoding the putative nematocyst venom proteins: a metallopeptidase related to the Tolloid family and a cysteine-rich protein. Both transcripts were detected in nematocytes, which are the cells containing nematocysts, and the metallopeptidase was found also in pharyngeal gland cells. Our findings reveal for the first time the possible venom components of a sea anemone nematocyst and suggest their evolutionary origins.

Developing a tool to preserve eye contact with patients undergoing colonoscopy for pain monitoring.

Colonoscopy has become the leading procedure for early detection and prevention of colorectal cancer. Patients' experience of colonic endoscopic procedures is scarcely reported, even though it is considered a major factor in colorectal cancer screening participation. Pain due to air inflation or stretching the colon with an endoscope is not rare during examination and may be the main obstacle to cooperation and participation in a screening program. We propose a four-stage study for developing a tool dedicated to pain monitoring during colonoscopy, as follows: (1) comparison of patient, nurse, and endoscopist questionnaire responses about patient pain and technical details of the procedure using the PAINAD tool during colonoscopy; (2) observation of the correlation between patients' facial expressions and other parameters (using the short PAINAD); (3) development of a device for continuous monitoring of the patient's facial expression during the procedure; (4) assessment of the usability of such a tool and its contribution to the outcomes of colonoscopy procedures. Early intervention by the staff performing the procedure, in reaction to alerts encoded by this tool, may prevent adverse events during the procedure.

Analysis of 7-year physician-reported adverse events in esophagogastroduodenoscopy.

INTRODUCTION: The number of negligence claims against physicians and health institutes is increasing and has become a serious financial problem. Reporting adverse events became a mandatory behavior for quality assurance purposes and for preparing potential claims. AIM: To evaluate endoscopists' reports on adverse events in esophagogastroduodenoscopy (EGD). METHODS: We analyzed all the reports of gastroenterologists on EGD adverse events to the risk management authority, between January 1, 2000, and December 31, 2006. Clinical and epidemiological details about the patients, procedures, and adverse events were computed, discussed, and evaluated. RESULTS: Thirty-nine cases of EGD adverse events were reported. There were 15 cases (38.5%) of men, and the average age was 58.1±21.6 years. In this period, 314,803 EGDs were performed by the institutes concerned, and the number of adverse events was 0.5 to 2.3 for 10,000 EGDs per year. Perforation occurred in 1 of 31,480 procedures, bleeding in 1 of 39,350 procedures, and respiratory complications in 1 of 157,401 procedures. Trauma to teeth happened in 1:31,480 procedures. CONCLUSIONS: This is the first study in Israel about physicians' reports of EGD adverse events. Reporting adverse events in EGD should be encouraged for improving patients' safety.

Transdermal delivery of scopolamine by natural submicron injectors: in-vivo study in pig.

Transdermal drug delivery has made a notable contribution to medical practice, but has yet to fully achieve its potential as an alternative to oral delivery and hypodermic injections. While transdermal delivery systems would appear to provide an attractive solution for local and systemic drug delivery, only a limited number of drugs can be delivered through the outer layer of the skin. The most difficult to deliver in this way are hydrophilic drugs. The aquatic phylum Cnidaria, which includes sea anemones, corals, jellyfish and hydra, is one of the most ancient multicellular phyla that possess stinging cells containing organelles (cnidocysts), comprising a sophisticated injection system. The apparatus is folded within collagenous microcapsules and upon activation injects a thin tubule that immediately penetrates the prey and delivers its contents. Here we show that this natural microscopic injection system can be adapted for systemic transdermal drug delivery once it is isolated from the cells and uploaded with the drug. Using a topically applied gel containing isolated natural sea anemone injectors and the muscarinic receptor antagonist scopolamine, we found that the formulated injectors could penetrate porcine skin and immediately deliver this hydrophilic drug. An in-vivo study in pigs demonstrated, for the first time, rapid systemic delivery of scopolamine, with T(max) of 30 minutes and C(max) 5 times higher than in controls treated topically with a scopolamine-containing gel without cnidocysts. The ability of the formulated natural injection system to penetrate a barrier as thick as the skin and systemically deliver an exogenous compound presents an intriguing and attractive alternative for hydrophilic transdermal drug delivery.

Immediate topical drug delivery by natural submicron injectors.

Transdermal delivery is an attractive but challenging solution for delivery of drugs. The sea anemone possesses a sophisticated injection system, which utilizes built-in high osmotic pressures. The system is folded within microcapsules and upon activation it injects a long, needle-like tubule of submicron diameter that penetrates the target in a fraction of a second. Here we show that this natural injection system can be adapted for active topical drug delivery once it is isolated from the cells, formulated into a topical gel, and uploaded with the desired drug. The formulated injectors retained their physical characteristics and were capable of penetrating the skin, achieving immediate delivery of a hydrophilic compound. We demonstrate quantitative rapid delivery of lidocaine hydrochloride as a function of microcapsular and drug concentrations. The adaptation of natural injectors for drug delivery combines the benefits of short topical application with rapid delivery of physical devices, thereby presenting a promising alternative for transdermal drug delivery.

Complications in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS): analysis of 7-year physician-reported adverse events.

INTRODUCTION: The number of malpractice claims against physicians and health institutes is increasing continuously in Israel as in the rest of the Western world, and has become a serious financial burden. AIM: In this study we analyzed the reports of gastroenterologists on endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) adverse events to the risk management authority between January 1, 2000 and December 31, 2006. METHODS: All the reported adverse events associated with ERCP and EUS of health institutes and covered by Madanes Insurance Agency were summarized and analyzed. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an Excel worksheet, discussed, and evaluated. RESULTS: Forty-two cases of ERCP and EUS adverse events were reported. There were nine cases of men (21.4%) and the average age was 69.3 ± 14.3 years. During this period, 10,647 procedures were performed by the institutes concerned and the number of adverse events was 20.2 to 67.8 per year for 10,000 procedures. Perforation occurred in one out of 367 procedures, bleeding in one out of 5323 procedures, teeth trauma in one out of 5323 procedures, and respiratory complications in one out of 10,647 procedures. CONCLUSION: This is the first study in Israel about physicians' reports of ERCP and EUS adverse events. Physicians reported only about severe adverse events with high rate of mortality and morbidity.

Complications in colonoscopy: analysis of 7-year physician-reported adverse events.

INTRODUCTION: The number of malpractice claims against physicians and health institutes in Israel is increasing continuously, as in the rest of the Western world. This trend became a serious financial burden. AIM: In this study we analyzed reports of gastroenterologists on colonoscopy adverse events to the medical malpractice insurer, as well as complaint/demand for compensation from patients represented by lawyers, between 1 January 2000 and 31 December 2006. METHODS: All the reports of physicians associated with colonoscopy adverse events from health institutes covered by Madanes Insurance Group were analyzed and summarized using a specially designed questionnaire. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an excel sheet, discussed, and evaluated. RESULTS: One hundred and two cases of colonoscopy adverse events were reported. There were 48 cases of men (47.1%) and the average age was 69.9±12.90 years. In this period of time 252 064 colonoscopies were performed by the institutes in the sampling frame, and the number of adverse events was on average 4.0 (between 2.8 and 6.2) for 10 000 colonoscopies. The difference between the years was not statistically significant. Perforation occurred in one of 2864 procedures, bleeding in one of 29 007 procedures, and respiratory complications in one of 50 412 procedures. CONCLUSION: This is the first study in Israel based on physicians' reports of colonoscopic adverse events. The picture is optimistic, as the rate of complications is low, and the data encourage early detection and reporting.

Diversity of aerobic and anaerobic ammonia-oxidizing bacteria in marine sponges.

Aerobic ammonia-oxidizing bacteria (AAOB) are known to have an important function in the marine nitrogen cycle. Anaerobic ammonium oxidation (anammox) carried out by some members of Planctomycetales is also an important process in marine ecosystems. Ammonia-monooxygenase gene (amoA) fragments were amplified to investigate the potential for nitrification and the diversity of the AAOB in two marine sponges Ircinia strobilina and Mycale laxissima. All of the AmoA sequences obtained from the two sponges clustered with the AmoA sequences of the Betaproteobacteria Nitrosospira spp. To investigate the anaerobic ammonia-oxidizing bacteria (AnAOB) in sponges, 16S rRNA gene fragments of Planctomycetales and anammox bacteria were also amplified with specific primers, and clone libraries were constructed. The Planctomycetales diversity detected in the two sponges was different. The Planctomycetales community in M. laxissima was affiliated with Pirellula, Planctomyces and anammox bacteria, while all of the I. strobilina Planctomycetales clones were solely affiliated with the candidate phylum 'Poribacteria'. Interestingly, sequences related to anammox genera were recovered only from M. laxissima. This is the first report of anammox bacteria in marine sponges. It is intriguing to find AAOB and AnAOB in M. laxissima, but the nature of their interaction with the sponge host and with each other remains unclear. This work further supports the potential of sponge-associated microorganisms for nitrification and sheds light on anammox as a new aspect of the nitrogen cycle in marine sponges.

Diversity and expression of nitrogen fixation genes in bacterial symbionts of marine sponges.

Marine sponges contain complex assemblages of bacterial symbionts, the roles of which remain largely unknown. We identified diverse bacterial nifH genes within sponges and found that nifH genes are expressed in sponges. This is the first demonstration of the expression of any protein-coding bacterial gene within a sponge. Two sponges Ircinia strobilina and Mycale laxissima were collected from Key Largo, Florida and had delta(15)N values of c. 0-1 per thousand and 3-4 per thousand respectively. The potential for nitrogen fixation by symbionts was assessed by amplification of nifH genes. Diverse nifH genes affiliated with Proteobacteria and Cyanobacteria were detected, and expression of nifH genes affiliated with those from cyanobacteria was detected. The nifH genes from surrounding seawater were similar to those of Trichodesmium and clearly different from the cyanobacterial nifH genes detected in the two sponges. This study advances understanding of the role of bacterial symbionts in sponges and suggests that provision of fixed nitrogen is a means whereby symbionts benefit sponges in nutrient-limited reef environments. Nitrogen fixation by sponge symbionts is possibly an important source of new nitrogen to the reef environment that heretofore has been neglected and warrants further investigation.