Brucella Exposure Risk Events in 10 Clinical Laboratories, New York City, USA, 2015 to 2017.

From 2015 to 2017, 11 confirmed brucellosis cases were reported in New York City, leading to 10 Brucella exposure risk events (Brucella events) in 7 clinical laboratories (CLs). Most patients had traveled to countries where brucellosis is endemic and presented with histories and findings consistent with brucellosis. CLs were not notified that specimens might yield a hazardous organism, as the clinicians did not consider brucellosis until they were notified that bacteremia with Brucella was suspected. In 3 Brucella events, the CLs did not suspect that slow-growing, small Gram-negative bacteria might be harmful. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), which has a limited capacity to identify biological threat agents (BTAs), was used during 4 Brucella events, which accounted for 84% of exposures. In 3 of these incidents, initial staining of liquid media showed Gram-positive rods or cocci, including some cocci in chains, suggesting streptococci. Over 200 occupational exposures occurred when the unknown isolates were manipulated and/or tested on open benches, including by procedures that could generate infectious aerosols. During 3 Brucella events, the CLs examined and/or manipulated isolates in a biological safety cabinet (BSC); in each CL, the CL had previously isolated Brucella Centers for Disease Control and Prevention recommendations to prevent laboratory-acquired brucellosis (LAB) were followed; no seroconversions or LAB cases occurred. Laboratory assessments were conducted after the Brucella events to identify facility-specific risks and mitigations. With increasing MALDI-TOF MS use, CLs are well-advised to adhere strictly to safe work practices, such as handling and manipulating all slow-growing organisms in BSCs and not using MALDI-TOF MS for identification until BTAs have been ruled out.

Validation of droplet digital PCR for the detection and absolute quantification of Borrelia DNA in Ixodes scapularis ticks.

We evaluated the QX200 Droplet Digital PCR (ddPCR™, Bio-Rad) system and protocols for the detection of the tick-borne pathogens Borrelia burgdorferi and Borrelia miyamotoi in Ixodes scapularis nymphs and adults collected from North Truro, Massachusetts. Preliminary screening by nested PCR determined positive infection levels of 60% for B. burgdorferi in these ticks. To investigate the utility of ddPCR as a screening tool and to calculate the absolute number of bacterial genome copies in an infected tick, we adapted previously reported TaqMan®-based qPCR assays for ddPCR. ddPCR proved to be a reliable means for detection and absolute quantification of control bacterial DNA with precision as low as ten spirochetes in an individual sample. Application of this method revealed the average carriage level of B. burgdorferi in infected I. scapularis nymphs to be 2291 spirochetes per nymph (range: 230-5268 spirochetes) and 51 179 spirochetes on average in infected adults (range: 5647-115 797). No ticks naturally infected with B. miyamotoi were detected. The ddPCR protocols were at least as sensitive to conventional qPCR assays but required fewer overall reactions and are potentially less subject to inhibition. Moreover, the approach can provide insight on carriage levels of parasites within vectors.

Frequency and Distribution of Rickettsiae, Borreliae, and Ehrlichiae Detected in Human-Parasitizing Ticks, Texas, USA.

To describe the presence and distribution of tickborne bacteria and their vectors in Texas, USA, we screened ticks collected from humans during 2008-2014 for Rickettsia, Borrelia, and Ehrlichia spp. Thirteen tick species were identified, and 23% of ticks carried bacterial DNA from at least 1 of the 3 genera tested.

The devil is in the details: Variable impacts of season, BMI, sampling site temperature, and presence of insects on the post-mortem microbiome.

Background: Post-mortem microbial communities are increasingly investigated as proxy evidence for a variety of factors of interest in forensic science. The reported predictive power of the microbial community to determine aspects of the individual's post-mortem history (e.g., the post-mortem interval) varies substantially among published research. This observed variation is partially driven by the local environment or the individual themselves. In the current study, we investigated the impact of BMI, sex, insect activity, season, repeat sampling, decomposition time, and temperature on the microbial community sampled from donated human remains in San Marcos, TX using a high-throughput gene-fragment metabarcoding approach. Materials and methods: In the current study, we investigated the impact of BMI, sex, insect activity, season, repeat sampling, decomposition time, and temperature on the microbial community sampled from donated human remains in San Marcos, TX using a high-throughput gene-fragment metabarcoding approach. Results: We found that season, temperature at the sampling site, BMI, and sex had a significant effect on the post-mortem microbiome, the presence of insects has a homogenizing influence on the total bacterial community, and that community consistency from repeat sampling decreases as the decomposition process progresses. Moreover, we demonstrate the importance of temperature at the site of sampling on the abundance of important diagnostic taxa. Conclusion: The results of this study suggest that while the bacterial community or specific bacterial species may prove to be useful for forensic applications, a clearer understanding of the mechanisms underpinning microbial decomposition will greatly increase the utility of microbial evidence in forensic casework.

Phylogenetic diversity of two common Trypanosoma cruzi lineages in the Southwestern United States.

Trypanosoma cruzi is the causative agent of Chagas disease, a devastating parasitic disease endemic to Central and South America, Mexico, and the USA. We characterized the genetic diversity of Trypanosoma cruzi circulating in five triatomine species (Triatoma gerstaeckeri, T. lecticularia, T.indictiva, T. sanguisuga and T. recurva) collected in Texas and Southern Arizona using multilocus sequence typing (MLST) with four single-copy loci (cytochrome oxidase subunit II- NADH dehydrogensase subunit 1 region (COII-ND1), mismatch-repair class 2 (MSH2), dihydrofolate reductase-thymidylate synthase (DHFR-TS) and a nuclear gene with ID TcCLB.506529.310). All T. cruzi variants fall in two main genetic lineages: 75% of the samples corresponded to T. cruzi Discrete Typing Unit (DTU) I (TcI), and 25% to a North American specific lineage previously labelled TcIV-USA. Phylogenetic and sequence divergence analyses of our new data plus all previously published sequence data from those four loci collected in the USA, show that TcIV-USA is significantly different from any other previously defined T. cruzi DTUs. The significant level of genetic divergence between TcIV-USA and other T. cruzi DTUs should lead to an increased focus on understanding the epidemiological importance of this DTU, as well as its geographical range and pathogenicity in humans and domestic animals. Our findings further corroborate the fact that there is a high genetic diversity of the parasite in North America and emphasize the need for appropriate surveillance and vector control programs for Chagas disease in southern USA and Mexico.

Controlled spatial and conformational display of immobilised bone morphogenetic protein-2 and osteopontin signalling motifs regulates osteoblast adhesion and differentiation in vitro.

BACKGROUND: The interfacial molecular mechanisms that regulate mammalian cell growth and differentiation have important implications for biotechnology (production of cells and cell products) and medicine (tissue engineering, prosthetic implants, cancer and developmental biology). We demonstrate here that engineered protein motifs can be robustly displayed to mammalian cells in vitro in a highly controlled manner using a soluble protein scaffold designed to self assemble on a gold surface. RESULTS: A protein was engineered to contain a C-terminal cysteine that would allow chemisorption to gold, followed by 12 amino acids that form a water soluble coil that could switch to a hydrophobic helix in the presence of alkane thiols. Bioactive motifs from either bone morphogenetic protein-2 or osteopontin were added to this scaffold protein and when assembled on a gold surface assessed for their ability to influence cell function. Data demonstrate that osteoblast adhesion and short-term responsiveness to bone morphogenetic protein-2 is dependent on the surface density of a cell adhesive motif derived from osteopontin. Furthermore an immobilised cell interaction motif from bone morphogenetic protein supported bone formation in vitro over 28 days (in the complete absence of other osteogenic supplements). In addition, two-dimensional patterning of this ligand using a soft lithography approach resulted in the spatial control of osteogenesis. CONCLUSION: These data describe an approach that allows the influence of immobilised protein ligands on cell behaviour to be dissected at the molecular level. This approach presents a durable surface that allows both short (hours or days) and long term (weeks) effects on cell activity to be assessed. This widely applicable approach can provide mechanistic insight into the contribution of immobilised ligands in the control of cell activity.

Comparison of the Bacterial Gut Microbiome of North American Triatoma spp. With and Without Trypanosoma cruzi.

Chagas disease, caused by the hemoflagellate protist Trypanosoma cruzi, affects nearly 6 million people worldwide, mainly in Latin America. Hematophagous triatomine insects ("kissing bugs") are the primary vectors of T. cruzi throughout the Americas and feed on a variety of animals, including humans. Control of triatomines is central to the control of T. cruzi infection. Recent advances in mitigation of other insect-borne diseases via the manipulation of insect-associated bacteria as a way to halt or slow disease transmission has opened questions to the applicability of these methods to Chagas disease vectors. Few studies have examined the hindgut microbiome of triatomines found in North America. In the current study, two species of triatomines were collected across Texas, United States, screened for the presence of T. cruzi, and analyzed for the bacterial composition of their hindguts using a 16S rRNA gene-fragment metabarcoding approach. We compared diversity of microbial community profiles across 74 triatomine insects to address the hypothesis that the richness and abundance of bacterial groups differ by T. cruzi infection and strain type, blood meal engorgement status, insect species, sex, and collection location. The gut microbial community of individual triatomines was characterized by low intraindividual taxonomic diversity and high interindividual variation that was weakly predicted by triatomine species, and was not predicted by triatomine sex, collection location, T. cruzi infection status, or blood meal score. However, we did find bacterial groups enriched in T. cruzi-positive individuals, including Enterobacterales, and Petrimonas. Additionally, we detected Salmonella enterica subspecies diarizonae in three triatomine individuals; this species is commonly associated with reptiles and domesticated animals and is a pathogen of humans. These data suggest that Triatoma spp. in Texas have variable patterns of colonized and transient bacteria, and may aid in development of novel means to interfere with transmission of the Chagas disease parasite T. cruzi. Deeper understanding of the effects of parasite infection on diverse insect vector microbiomes may highlight disease transmission risk and facilitate discovery of possible intervention strategies for biological control of this emerging vector-borne disease of global health significance.

Neurosteroid modulation of GABAA receptors: molecular determinants and significance in health and disease.

Over the past 20 years it has become apparent that certain steroids, synthesised de novo in the brain, hence named neurosteroids, produce immediate changes (within seconds) in neuronal excitability, a time scale that precludes a genomic locus of action. Identified molecular targets underlying modulation of brain excitability include both the inhibitory GABA(A) and the excitatory NMDA receptor. Of particular interest is the interaction of certain neurosteroids with the GABA(A) receptor, the major inhibitory receptor in mammalian brain. During the last decade, compelling evidence has accrued to reveal that locally produced neurosteroids may selectively "fine tune" neuronal inhibition. A range of molecular mechanisms including the subunit composition of the receptor(s), phosphorylation and local steroid metabolism, underpin the region- and neuronal selectivity of action of neurosteroids at synaptic and extrasynaptic GABA(A) receptors. The relative contribution played by each of these mechanisms in a variety of physiological and pathophysiological scenarios is currently being scrutinised at a cellular and molecular level. However, it is not known how such mechanisms may act in concert to influence behavioural profiles in health and disease. An important question concerns the identification of the anatomical substrates mediating the repertoire of behaviours produced by neurosteroids. "Knock-in" mice expressing mutant GABA(A) subunits engineered to be insensitive to benzodiazepines or general anaesthetics have proved invaluable in evaluating the role of GABA(A) receptor subtypes in complex behaviours such as sedation, cognition and anxiety [Rudolph, U., Mohler, H., 2006. GABA-based therapeutic approaches: GABA(A) receptor subtype functions. Curr. Opin. Pharmacol. 6, 18-23]. However, the development of a similar approach for neurosteroids has been hampered by the limited knowledge that, until recently, has surrounded the identity of the amino acid residues contributing to the neurosteroid binding pocket. Here, we will review recent progress in identifying the neurosteroid binding site on the GABA(A) receptor, and discuss how these discoveries will impact on our understanding of the role of neurosteroids in health and disease.

Thermodynamic analysis does not allow discrimination of agonists and antagonists at human CCK2S-receptors.

Studies have shown that measurement of thermodynamic parameters (enthalpy, DeltaH degrees and entropy, DeltaS degrees ) can allow discrimination of agonists and antagonists (e.g. Weiland, G.A., Minneman, K.P., Molinoff, P.B., 1979. Fundamental difference between the molecular interactions of agonists and antagonists with the beta-adrenergic receptor. Nature, 281, 114.). Recently, we found that agonists and antagonists were not thermodynamically-distinguished at cholecystokinin (CCK)2-receptors in rat cerebral cortex. However, in this study, the possibility that thermodynamic discrimination at CCK2-receptors exists but that it was not detected, could not be excluded because radioligand binding studies and functional assays were performed in different rat tissues. Therefore, we have repeated these studies using the recombinant CCK2 short isoform (CCK2S)-receptor expressed in NIH3T3 cells, so that ligand affinity (pKI) and intrinsic activity (alpha) measurements could be made in exactly the same receptor system. CCK-8S but not R-L-365,260, S-L-365,260, JB95008, JB93242 or PD134,308 expressed intrinsic activity in an IP assay. The pKD of [3H]-JB93182 decreased with increasing temperature. pKI values for antagonists (R-L-365,260, S-L-365,260, JB95008) and agonists (pentagastrin, CCK-8S) were higher at 4 than at 30 degrees C. There was no effect of temperature on pKI values for the antagonists, PD134,308 and JB93242. Therefore, CCK2-receptor agonists and antagonists at human CCK2S-receptors cannot be discriminated by thermodynamic analysis.

ECMO: Incidence and Outcomes of Patients Undergoing the Hybrid Procedure.

OBJECTIVE: To document the extracorporeal membrane oxygenation (ECMO) incidence and outcome in patients undergoing the hybrid procedure at an institution that routinely performs this procedure. DESIGN: A retrospective chart review on all patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. Patients were excluded if they underwent the hybrid procedure after 60 days of birth or subsequently underwent a biventricular repair. SETTING: A single center, tertiary pediatric hospital. PATIENTS: One hundred eighty-one patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied a total of 181 patients (105 males: 76 females). Gestational age was 37.8 ± 2.0 weeks and birth weight was 3.0 ± 0.7 kg. Underlying diagnosis was hypoplastic left heart syndrome in 149 patients and other in 32 patients. Age at surgery was 7.8 ± 6.8 days and weight at surgery was 3.1 ± 0.6 kg. Two patients underwent ECMO support after the hybrid procedure. One patient had aortic atresia/mitral atresia and weighed 2.3 kg and the other patient had aortic atresia/mitral stenosis and weighed 2.1 kg at time of surgery. Both patients died. Incidence of ECMO support after hybrid procedure was 1.3% (2/149) for the hypoplastic left heart syndrome patients and 1.1% (2/181) for the entire cohort. CONCLUSION: Mortality in patients who underwent ECMO after the hybrid procedure was higher than reported for the Norwood procedure, however, the incidence of ECMO after hybrid procedure was also significantly lower than reported for the Norwood procedure. Future studies are needed to determine how to improve outcomes in this complex patient population.

Towards rehabilitative handling in caring for patients following stroke: a participatory action research project.

AIM OF THE STUDY: This study aimed to facilitate nurses to take ownership of their moving and handling practice. OBJECTIVES: To (i) facilitate nurses in sharing their insights in moving and handling patients following stroke, (ii) enable nurses to identify facilitators of safer moving and handling practice, and (iii) empower nurses in collaboration with physiotherapists to direct changes in their practice. BACKGROUND: Traditional top down moving and handling training has had variable impact on nursing practice. A moving and handling incident in a stroke unit demonstrated that there were professional development needs for staff in the stroke unit in relation to their moving and handling practice in the care of patients following stroke. METHODS: An insider participatory action research approach was utilized. Data were analysed from focus group meetings, brainstorming sessions, observational studies, and from written reflective accounts. FINDINGS: Peer pressure, communication, rehabilitative handling awareness, teamwork between nurses and physiotherapists, equipment and environmental issues were affecting moving and handling practice. Nurses identified that equipment, environment, communication and teamwork strategies would facilitate them in using rehabilitative moving and handling practice. Nurses in collaboration with physiotherapists directed changes in their practice. Participant staff members felt involved and valued, and reported changes in understanding, in their handling practice, and enhanced teamwork. CONCLUSION: Participatory action research creates a supportive environment, where those directly involved in moving and handling patients can investigate and direct changes in their practice. Thus it is a significant vehicle for delivering professional development in moving and handling practice. Relevance to clinical practice. Professional development initiatives in moving and handling practice must incorporate processes that enhance inter-disciplinary teamwork and value and utilize the views and experiences of the staff who move and handle patients.

Aortic root thrombosis with coronary embolization following neo-aortic reconstruction in a child with hypoplastic left heart syndrome.

In the recent era, the diagnosis, treatment options, postoperative management and outcomes of infants born with hypoplastic left heart syndrome (HLHS) have undergone dramatic changes. As is the case with many other novel treatment modalities used for congenital heart diseases, data concerning the long-term outcomes and complications of the various strategies become gradually more available as the numbers of survivors grow. In general, complications of the three-stage surgical palliation used for HLHS tend to occur most commonly following the first-stage surgery. Post-stage 2 complications are substantially less common, and centre on the procedure itself and the unique physiology of the cavopulmonary connection. In the following case report, we describe a relatively rare adverse outcome that occurred following a stage 2 surgery in the form of native aortic root thrombosis extending to the coronary arteries. The selected methods of treatment used in the catheterization laboratory and later in the operating theatre, as well as its outcomes are described.

Extrasynaptic glycine receptors of rodent dorsal raphe serotonergic neurons: a sensitive target for ethanol.

Alcohol abuse is a significant medical and social problem. Several neurotransmitter systems are implicated in ethanol's actions, with certain receptors and ion channels emerging as putative targets. The dorsal raphe (DR) nucleus is associated with the behavioral actions of alcohol, but ethanol actions on these neurons are not well understood. Here, using immunohistochemistry and electrophysiology we characterize DR inhibitory transmission and its sensitivity to ethanol. DR neurons exhibit inhibitory 'phasic' post-synaptic currents mediated primarily by synaptic GABAA receptors (GABAAR) and, to a lesser extent, by synaptic glycine receptors (GlyR). In addition to such phasic transmission mediated by the vesicular release of neurotransmitter, the activity of certain neurons may be governed by a 'tonic' conductance resulting from ambient GABA activating extrasynaptic GABAARs. However, for DR neurons extrasynaptic GABAARs exert only a limited influence. By contrast, we report that unusually the GlyR antagonist strychnine reveals a large tonic conductance mediated by extrasynaptic GlyRs, which dominates DR inhibition. In agreement, for DR neurons strychnine increases their input resistance, induces membrane depolarization, and consequently augments their excitability. Importantly, this glycinergic conductance is greatly enhanced in a strychnine-sensitive fashion, by behaviorally relevant ethanol concentrations, by drugs used for the treatment of alcohol withdrawal, and by taurine, an ingredient of certain 'energy drinks' often imbibed with ethanol. These findings identify extrasynaptic GlyRs as critical regulators of DR excitability and a novel molecular target for ethanol.

Diversity of piroplasms detected in blood-fed and questing ticks from several states in the United States.

Piroplasms in the genera Babesia, Theileria, and Cytauxzoon are tick-borne parasites that may be animal and human pathogens. Most piroplasms with known life cycles are transmitted by ixodid ticks; however, for many species, the vector is unknown. This study was conducted to determine the prevalence and diversity of piroplasms in ticks from several US states. Piroplasm-specific polymerase chain reaction (PCR) assays were used to test 1631 ticks from Georgia (n=486), Kentucky (n=103), Pennsylvania (n=1), Tennessee (n=626), and Texas (n=414). Ticks were either questing (n=42) or collected from animals (n=627) or humans (n=962). The 2 primary species tested were Dermacentor variabilis (n=702) and Amblyomma americanum (n=743), but Amblyomma cajennense (n=99), Amblyomma maculatum (n=16), Ixodes scapularis (n=4), I. woodi (n=1), and unidentified Amblyomma spp. nymphs (n=64) were also tested. A low prevalence of piroplasms was detected with 37 (2.3%), 35 (2.1%), and 9 (0.6%) ticks positive for Theileria spp., Babesia spp., or Cytauxzoon felis, respectively. Based on sequence analysis, at least 6 Babesia spp. were detected and 15 of the 35 (41%) Babesia-positive ticks were A. americanum, 19 (56%) were D. variabilis, and one (3%) was an I. scapularis. Nine Babesia-positive ticks were removed from humans from Kentucky (n=1), Georgia (n=2), Texas (n=5), and Pennsylvania (n=1). Three Babesia-positive ticks were questing A. americanum which represents the first report of Babesia-infected questing Amblyomma in the US. Theileria infections were only detected in A. americanum, and all sequences were similar to white-tailed deer associated Theileria spp. C. felis was only detected in D. variabilis. These data suggest that A. americanum may be a vector of Babesia spp., although experimental studies are needed to confirm vector competence. Finally, these data demonstrate a high diversity of piroplasms in both questing and partially fed ticks in the US; although, host-blood meals can be present in non-questing ticks.

'With a bit of tweaking we could be great'. An exploratory study of the perceptions of students on working with older people in a preregistration BSc (Hons) Nursing course.

BACKGROUND: With ageing demographics, it is important that nurse education curriculum can prepare students to work with older people. AIMS AND OBJECTIVES: To explore students' perceptions of working with older people and the extent to which their preregistration curriculum is preparing them for this role. DESIGN: A qualitative research design, incorporating focus groups in data collection. METHODS: Four focus groups were held in January 2011, involving a total of 32 students undertaking a preregistration BSc (Hons) nursing degree course. RESULTS: An overt focus in the preregistration curriculum on acute and critical care and perceived deficits in care of older people content left some students feeling underprepared to work with older people and to challenge ritualistic practice. Clinical placement experience and mentor support appeared to be influencing students' decisions about whether they would consider working with older people in the future. CONCLUSION: Education providers should ensure that students are adequately prepared to work with older people and that students are supported when they observe poor practice. A finding that observation of ritualistic practice could prompt some students to consider working with older people, warrants further research. Implications for practice. Nurse educators should evaluate the content and delivery of their preregistration courses to ensure that the prerequisite knowledge, skills and attitudes required to work with older people are accorded appropriate value and attention.

Nurse-patient encounters in the hospital ward, from the perspectives of older persons: an analysis using the Authentic Consciousness Framework.

BACKGROUND: Despite a growing theoretical base to support the development of person-centred practice, the evidence would suggest that this way of working is somewhat elusive in the care of older people. AIMS: The study aims to explore nurse-older person encounters and relationships within the context of person-centredness. DESIGN AND METHODS: This study involved secondary analysis of interview data originally collected from a commissioned study investigating whole-systems approaches in services for older people. The process of analysis used the Authentic Consciousness Framework. RESULTS: Nurses are often invisible to the patient, unless they are providing care to address a physical need. A sense of rolelessness pervaded the data, when patients were deprived from actively participating in important decisions about their future care. CONCLUSIONS: Patients would like nurses to work with them in more transparent ways. Patients are very conscious that nurses are busy and attempt to share the coping with the busy workload by limiting their expectations of the nurse. RELEVANCE TO CLINICAL PRACTICE: Person-centred strategies must enhance the capacity of not only older patients and their ability to assert self, but also the capacity of their nurses. Nurses must work to actively recruit the patient in all decision making.

Perceptions and implications of violence from care home residents with dementia: a review and commentary.

AIMS AND OBJECTIVES: This paper presents a critical review of the literature related to the violence staff in care homes experience from people with dementia. It attempts to identify the psychological consequences abuse has on care workers and the implications this has for practice. BACKGROUND: Abuse in the form of violence or aggression against healthcare professionals is not new. However, when this is from residents with dementia in care homes it is considered to be part of the job. Consequently it is largely underreported and ignored which masks its true extent. CONCLUSION: The magnitude of violence in care homes crosses cultural boundaries. Fear of being blamed, job insecurity and resignation that abuse should be accepted as part of the job is unique to this care setting. The cumulative effect of psychological abuse leads to emotional exhaustion and depersonalisation which results in care workers emotionally and physically withdrawing from residents. Being subjected to abuse, feeling undervalued, unsupported and lacking essential skills may compromise a workforces' ability to provide person-centred care. A rising ageing population and prevalence of dementia will place demands on commissioners and providers to deliver high quality care. Consistent recording and reporting procedures, dementia specific training and infrastructures to support staff is therefore crucial.

Attitudes of Healthcare Workers towards Older People in a Rural Population: A Survey Using the Kogan Scale.

With the global trend towards an increasingly ageing population, it is clear that nurses need to be equipped with the knowledge and skills to fulfil significant roles in responding to future health and support needs. This paper reports the results of a survey that aimed to identify and evaluate the attitudes of nurses, healthcare assistants, and nursing students towards older people. The survey was undertaken in a rural county in the Republic of Ireland. It is reassuring that in our study, we found that these healthcare workers hold positive attitudes towards older people. In addition, we found that study to a higher level at university appears to mitigate towards holding more positive attitudes, and this is an important finding in light of the shift towards nursing as an all-graduate profession.

Older persons' experiences of whole systems: the impact of health and social care organizational structures.

AIMS: An in-depth case study of whole systems working. BACKGROUND: This paper reports on the second part of a two-part study exploring whole systems working. Part 1 of the study focused on an in-depth review of the literature pertaining to continuity of care and service integration. The second part, reported here, focused on an in-depth case study of one whole system. Evaluation Informed by the findings of part 1 of the study, data collection methods included in-depth interviews, real-time tracking of 18 older people, focus groups and consensus conferencing. Different data sets were analysed individually and synthesized using matrices derived from the literature review findings. KEY ISSUE: Key themes from data synthesis include: (1) access to the most appropriate services; (2) service fragmentation; (3) continuity of care; and (4) routinized care. CONCLUSIONS: The four themes of the case study reflect the need to address issues of demarcation of professional responsibilities, complicated channels of communication, information flows, assessment and reassessment in whole systems working. IMPLICATIONS FOR NURSING MANAGEMENT: The impact of disempowering relationships on actual continuity of care and perceptions of quality among service users and providers. Lessons need to be learnt from specialist services and applied to service delivery in general.

An exploratory study of web-enhanced learning in undergraduate nurse education.

AIM: The aim of the study was to explore undergraduate nursing students' views of web-enhanced learning and to examine issues relating to their pattern of access to a rehabilitation nursing module website. BACKGROUND: As information technology is an integral component of western health care, all nurses are expected to have the necessary knowledge, skills and attitudes to be competent in its use. METHODS: In phase 1, a focus group interview was conducted with students (n = 6) who had not logged onto a similar module website. In phase 2, a questionnaire was administered to students undertaking the web-enhanced module. In phase 3, each student's (n = 231) pattern of access to the module was identified and compared with the student's performance as evidenced by their module assignment mark. RESULTS: Students held favourable attitudes towards web-enhanced learning but some students experienced difficulties. There was a significant positive association between the students' assignment mark and the number of times logged onto the module website. Significant negative correlations were found between mark and week of first log on, and week of first log on and number of hits onto the module site. This suggests that students who logged onto the module in the first few weeks were more likely to achieve higher marks. CONCLUSIONS: This study's findings suggest that students who accessed the module website early and often were more likely to produce more comprehensive nursing assessments and consequently achieve higher assignment marks than their colleagues. RELEVANCE TO CLINICAL PRACTICE: The findings have relevance to all nurses as lifelong learning is a mandatory requirement for maintaining clinical competence and electronic learning can provide students (regardless of registration status) with the flexibility to gain access to course content at a time and place convenient to them. The role of electronic learning in promoting a more holistic nursing assessment is also discussed.