Whole-Genome sequencing in routine Mycobacterium bovis epidemiology - scoping the potential.

Mycobacterium bovis the main agent of bovine tuberculosis (bTB), presents as a series of spatially-localised micro-epidemics across landscapes. Classical molecular typing methods applied to these micro-epidemics, based on genotyping a few variable loci, have significantly improved our understanding of potential epidemiological links between outbreaks. However, they have limited utility owing to low resolution. Conversely, whole-genome sequencing (WGS) provides the highest resolution data available for molecular epidemiology, producing richer outbreak tracing, insights into phylogeography and epidemic evolutionary history. We illustrate these advantages by focusing on a common single lineage of M. bovis (1.140) from Northern Ireland. Specifically, we investigate the spatial sub-structure of 20 years of herd-level multi locus VNTR analysis (MLVA) surveillance data and WGS data from a down sampled subset of isolates of this MLVA type over the same time frame. We mapped 2108 isolate locations of MLVA type 1.140 over the years 2000-2022. We also mapped the locations of 148 contemporary WGS isolates from this lineage, over a similar geographic range, stratifying by single nucleotide polymorphism (SNP) relatedness cut-offs of 15 SNPs. We determined a putative core range for the 1.140 MLVA type and SNP-defined sequence clusters using a 50 % kernel density estimate, using cattle movement data to inform on likely sources of WGS isolates found outside of core ranges. Finally, we applied Bayesian phylogenetic methods to investigate past population history and reproductive number of the 1.140 M. bovis lineage. We demonstrate that WGS SNP-defined clusters exhibit smaller core ranges than the established MLVA type - facilitating superior disease tracing. We also demonstrate the superior functionality of WGS data in determining how this lineage was disseminated across the landscape, likely via cattle movement and to infer how its effective population size and reproductive number has been in flux since its emergence. These initial findings highlight the potential of WGS data for routine monitoring of bTB outbreaks.

Genomic epidemiology of Mycobacterium bovis infection in sympatric badger and cattle populations in Northern Ireland.

Bovine tuberculosis (bTB) is a costly, epidemiologically complex, multi-host, endemic disease. Lack of understanding of transmission dynamics may undermine eradication efforts. Pathogen whole-genome sequencing improves epidemiological inferences, providing a means to determine the relative importance of inter- and intra-species host transmission for disease persistence. We sequenced an exceptional data set of 619 Mycobacterium bovis isolates from badgers and cattle in a 100 km2 bTB 'hotspot' in Northern Ireland. Historical molecular subtyping data permitted the targeting of an endemic pathogen lineage, whose long-term persistence provided a unique opportunity to study disease transmission dynamics in unparalleled detail. Additionally, to assess whether badger population genetic structure was associated with the spatial distribution of pathogen genetic diversity, we microsatellite genotyped hair samples from 769 badgers trapped in this area. Birth death models and TransPhylo analyses indicated that cattle were likely driving the local epidemic, with transmission from cattle to badgers being more common than badger to cattle. Furthermore, the presence of significant badger population genetic structure in the landscape was not associated with the spatial distribution of M. bovis genetic diversity, suggesting that badger-to-badger transmission is not playing a major role in transmission dynamics. Our data were consistent with badgers playing a smaller role in transmission of M. bovis infection in this study site, compared to cattle. We hypothesize, however, that this minor role may still be important for persistence. Comparison to other areas suggests that M. bovis transmission dynamics are likely to be context dependent, with the role of wildlife being difficult to generalize.

Remembering Friends: Exploring the Bereavement Support Needs of Teenagers and Young Adults Experiencing the Death of a Friend in the Cancer Setting.

Introduction: Bereavement is often difficult for adolescents to cope with particularly when the death experienced is a friend due to cancer, while the young person is undergoing their own cancer treatment. There is limited research on this specific type of bereavement. The Teenage & Young Adult (TYA) team at The Christie in Manchester recognized the complicated nature of bereavement in this cohort and identified the need to research this area further. Methods: A mixed method research strategy was used to explore bereavement experiences of young people, gathering qualitative and quantitative data from a TYA bereavement advisory group and an online survey. Inductive thematic analysis was used to establish themes from the qualitative data. Results: Data from the advisory group and survey elicited four main themes: prevalence and emotional impact; maintaining and valuing friendships; communication and conversations; and support and space to grieve. Young people experienced multiple exposures to death, long-term emotional reactions, reflections on mortality, and fears of making new friendships. How a death was communicated was difficult, and bereavement support was lacking. Young people want a formalized bereavement service, provided by specially trained staff, and their own "space" to grieve. Conclusion: Young people in this study highlight the complicated nature of bereavement when their friend dies, while undergoing their own cancer treatment. Bereavement support is essential at the time of a death. TYA services bring young people together for peer support so more emphasis needs to be focused on providing bereavement support to reduce the risk of young people experiencing long-term psychological difficulties and negative outcomes later in life.

Genomic epizootiology of a Brucella abortus outbreak in Northern Ireland (1997-2012).

BACKGROUND: In the recent past (1997-2012), Northern Ireland in the United Kingdom suffered an outbreak of Brucella abortus, which at its height affected over 200 cattle herds. Initially, isolates were characterized using multi-locus variable number tandem repeats analysis (MLVA). While informative in this setting, hyper-variability in some loci limited the resolution necessary to infer fine-scale disease transmission networks. Consequently, we applied whole-genome sequencing to isolates from this outbreak to evaluate higher resolution markers for disease epizootiology. RESULTS: Phylogenetic analysis revealed that the B. abortus outbreak in Northern Ireland was caused by two distinct pathogen lineages. One contained isolates consistent with the 1997-2012 outbreak being linked to a previous endemic infection thought eradicated. The dominant second lineage exhibited little genetic diversity throughout the recrudescent outbreak, with limited population sub-structure evident. This finding was inconsistent with prior MLVA molecular characterizations that suggested the presence of seven clonal complexes. Spatio-temporal modeling revealed a significant association of pairwise SNP differences between isolates and geographic distances. However, effect sizes were very small due to reduced pathogen diversity. CONCLUSIONS: Genome sequence data suggested that hyper-variability in some MLVA loci contributed to an overestimate of pathogen diversity in the most recent outbreak. The low diversity observed in our genomic dataset made it inappropriate to apply phylodynamic methods to these data. We conclude that maintaining data repositories of genome sequence data will be invaluable for source attribution/epizootiological inference should recrudescence ever re-occur. However genomic epizootiological methods may have limited utility in some settings, such as when applied to recrudescent/re-emergent infections of slowly-evolving bacterial pathogens.

Older Adults and Their Families: An Interactional Intervention That Brings Forth Love and Softens Suffering.

When assisting older adults and their families, the most useful family nursing conceptual skill is embracing the belief that "illness is a family affair." This illness belief summons a systemic or interactional focus specifically on relationship communication patterns. Uncovering maladaptive and distressing familial interactions, a family nurse can intervene and offer ideas for more loving and caring interactional patterns. Three brief and one detailed clinical case example, illustrating how to conceptualize interactional patterns and how to intervene, are offered. This article also presents the author's firsthand caregiving experience with its accompanying joys and pitfalls. Despite her decades of clinical practice and professional assistance to numerous elderly families, the caregiving and interactions with her father held no guarantee of being filled with consistent care and love. Although not easily applicable to one's own family, focusing on the interrelationships with the elderly and their families, the embedded interactional patterns become the crucial ingredient to facilitate more satisfying and loving relationships.

Application of the Calgary Family Assessment and Intervention Models: Reflections on the Reciprocity Between the Personal and the Professional.

Much has been written about the global implementation of the Calgary Family Assessment and Intervention Models (CFAM/CFIM) and the application of these practice models in various clinical settings. The purpose of this article is to provide a brief update on the background of CFAM/CFIM, and the current applications of the models as evidenced in the English-language literature. Little has been written about the use of CFAM/CFIM in a personal context, however. As originators of the models, we offer our own narratives and reflections about the reciprocity between the personal and professional applications of our models and the ways that our personal experiences have extended our understanding about the utility of the models for clinical practice with families.

Brain science and illness beliefs: an unexpected explanation of the healing power of therapeutic conversations and the family interventions that matter.

Paradigm families and paradigm practice moments have shown me that therapeutic conversations between nurses and families can profoundly and positively change illness beliefs in family members and nurses and contribute to healing from serious illness. The integration of brain science into nursing practice offers further understanding of the importance of illness beliefs and the role they may play in helping individual and family healing. Brain science offers explanations that connect how certain family nursing interventions that soften suffering and challenge constraining illness beliefs may result in changes in brain structure and functioning. New illness beliefs may result in new neural pathways in the brain, and therefore, possibilities for a new way of being in relationship with illness and in relationship with others can also develop. Newly acquired practice skills and interventions that have emerged from an understanding of brain science plus the reemphasis of other interventions utilized in the Illness Beliefs Model are offered to enhance our care of families suffering with illness.

Integrating care for high-risk patients in England using the virtual ward model: lessons in the process of care integration from three case sites.

BACKGROUND: Patients at high risk of emergency hospitalisation are particularly likely to experience fragmentation in care. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation. OBJECTIVE: To describe the care practice in three virtual ward sites in England and to explore how well each site had achieved meaningful integration. METHOD: Case studies conducted in Croydon, Devon and Wandsworth during 2011-2012, consisting of semi-structured interviews, workshops, and site visits. RESULTS: Different versions of the virtual wards intervention had been implemented in each site. In Croydon, multidisciplinary care had reverted back to one-to-one case management. CONCLUSIONS: To integrate successfully, virtual ward projects should safeguard the multidisciplinary nature of the intervention, ensure the active involvement of General Practitioners, and establish feedback processes to monitor performance such as the number of professions represented at each team meeting.

What are the benefits of a short therapeutic conversation intervention with acute psychiatric patients and their families? A controlled before and after study.

BACKGROUND: Psychiatric illness of a family member can have a serious impact on the entire family. In addition, these families are faced with psychological burdens and stigmas. Little is known about the effectiveness of family nursing interventions on patients and their families when a family member is admitted for psychiatric treatment. Few studies have been published where family nursing interventions are integrated into routine inpatient services. PURPOSE: To evaluate the effectiveness of implementing a therapeutic conversation intervention in acute inpatient psychiatry with families, by evaluating family perceived support, expressive family function and general well-being. DESIGN AND METHODS: A controlled before and after study design was used. Patients and family members at four acute psychiatric units at a university hospital were selected for the implementation of family systems nursing (FSN). The nurses on one acute psychiatric unit were educated, trained, and supervised in a therapeutic conversation intervention built on the Calgary Family Assessment and Interventions models (Wright and Leahey, 2009). In the intervention group, 68 patients and 68 family members (N=136), received two-to-five therapeutic conversations with a nurse. The control groups were from three other acute units at the hospital, where 74 patients and 74 family members (N=148) received family nursing care as usual. RESULTS: The main findings indicated that family members who received the short therapeutic conversation intervention were found to perceive significant higher cognitive and emotional support from the nurses than family members who received standard care. CONCLUSION: The benefits of a specific short-term therapeutic conversation intervention are evident and valuable for nurses working in acute psychiatry. These positive results for families of psychiatric patients should not only encourage and propel clinical educators, clinical nurses and nurse researchers and other health professionals to develop and implement the therapeutic conversation intervention in acute psychiatric services but also be part of ritualized protocols of practice.

Multidisciplinary case management for patients at high risk of hospitalization: comparison of virtual ward models in the United kingdom, United States, and Canada.

Virtual wards are a model for delivering multidisciplinary case management to people who are at high predicted risk of unplanned acute care hospitalization. First introduced in Croydon, England, in 2006, this concept has since been adopted and adapted by health care organizations in other parts of the United Kingdom and internationally. In this article, the authors review the model of virtual wards as originally described-with its twin pillars of (1) using a predictive model to identify people who are at high risk of future emergency hospitalization, and (2) offering these individuals a period of intensive, multidisciplinary preventive care at home using the systems, staffing, and daily routines of a hospital ward. The authors then describe how virtual wards have been modified and implemented in 6 sites in the United Kingdom, United States, and Canada where they are subject to formal evaluation. Like hospital wards, virtual wards vary in terms of patient selection, ward configuration, staff composition, and ward processes. Policy makers and researchers should be aware of these differences when considering the evaluation results of studies investigating the cost-effectiveness of virtual wards.

Families' and nurses' responses to the "One Question Question": reflections for clinical practice, education, and research in family nursing.

The "One Question Question," first coined by Dr. Lorraine M. Wright in 1989, is an interventive question designed to elicit family members' most pressing needs or concerns within the context of a therapeutic conversation. In this article, two clinical projects analyzed the responses to this unique interventive question. The first project analyzed the responses of 192 family members experiencing illness who were asked the question in the context of a therapeutic conversation; families focused on their need to deal with the impact of the illness on the family. The second project examined responses of 297 nurses who were asked the question prior to a 1-week Family Systems Nursing training program; nurses wanted to know how to deal with conflictual relationships between families and health care professionals and how to offer families time-efficient interventions. The responses from both groups, which were markedly different, triggered reflections about teaching, research, and practice in family nursing.

Therapeutic letters and the family nursing unit: a legacy of advanced nursing practice.

This article focuses on the history of the use of therapeutic letters in the clinical scholarship of the Family Nursing Unit at the University of Calgary and offers examples of a variety of therapeutic letters written to families experiencing illness suffering. A case study from the research of Moules (2000, 2002) is offered to further illustrate the usefulness of therapeutic letters as a family nursing intervention.

Unraveling the new Form 990: implications for hospitals.

This article examines the recent significant changes to the Form 990 information return for tax-exempt organizations. Specifically, we address those changes to the return that may impact the health care industry. The Internal Revenue Service (IRS) argues the redesign of the Form 990 is based on the following three principles: enhancing transparency, promoting tax compliance, and minimizing the burden on the filing organization. It has yet to be determined whether the significant reorganization of the informational return will benefit the stakeholders of the health care industry. We argue that these changes are a step in the right direction in providing necessary disclosure for policymakers and federal regulators.

Living the as-yet unanswered: spiritual care practices in family systems nursing.

A serious illness often creates suffering and precipitates a search for spiritual meaning. The purpose of this hermeneutic inquiry was to explore the meaning of spirituality and spiritual care practices in family systems nursing. The videotapes of 12 therapeutic conversations with three families living with serious illness were the primary data for the inquiry. Findings suggest that suffering embodies an invitation to respond to the spiritual. Identified spiritual care practices included gathering stories of illness and faith, opening space to reinterpret experiences from a spiritual perspective, drawing on imagination and metaphor, and listening with an opening silence. The therapeutic work with one family is highlighted. This inquiry revealed that spiritual care requires literacy in reading the spiritual, a willingness to respond to the particular and the unpredictable, and a belief that good care demands a wise and thoughtful response to the suffering other.

Softening suffering through spiritual care practices: one possibility for healing families.

Nurses are engaged and encounter suffering routinely and commonly in their everyday practice. It is therefore a moral and ethical obligation for nurses to soften the emotional, physical, and spiritual suffering of the individuals and families in their care. Softening suffering is the heart of nursing. However, this article ponders the question, "What happened to suffering in nursing care?" A discussion of suffering is explored from many aspects, such as what invites suffering and the connection of suffering to spirituality. Lessons learned from the author's clinical practice and research are described, such as acknowledging suffering, social support, hope and prayer, and individual and family counseling. Finally, seven spiritual care practices within the Trinity Model that have shown to be useful in softening suffering are offered. An actual clinical example is woven throughout to illustrate the benefits of these spiritual care practices in the mission of softening illness suffering.

Exploring the therapeutic family intervention of commendations: insights from research.

Offered in this article are interpretations that emerged in a qualitative, interpretive study focused on the family intervention called a "commendation." The tradition of philosophical hermeneutics informs and shapes the analysis of the data. Research participants include a heterosexual couple and a nurse who engaged in therapeutic conversations focused on difficulties with Internet pornography. Data sources include videotapes of clinical sessions, documentation, and research interviews. Isolated segments of clinical videotape are shared with the couple to prompt their memory of commending practices that emerged in clinical sessions. Commendations are not experienced by this couple as gentle and warm but instead as extremely provocative, albeit constructive. This study illuminates the complex, contextual nature of commending practice and suggests that the noticing of strengths and resources contains much more than the spoken word.