Surveillance of vancomycin-resistant enterococci reveals shift in dominating clusters from vanA to vanB Enterococcus faecium clusters, Denmark, 2015 to 2022.

BackgroundVancomycin-resistant enterococci (VRE) are increasing in Denmark and Europe. Linezolid and vancomycin-resistant enterococci (LVRE) are of concern, as treatment options are limited. Vancomycin-variable enterococci (VVE) harbour the vanA gene complex but are phenotypically vancomycin-susceptible.AimThe aim was to describe clonal shifts for VRE and VVE in Denmark between 2015 and 2022 and to investigate genotypic linezolid resistance among the VRE and VVE.MethodsFrom 2015 to 2022, 4,090 Danish clinical VRE and VVE isolates were whole genome sequenced. We extracted vancomycin resistance genes and sequence types (STs) from the sequencing data and performed core genome multilocus sequence typing (cgMLST) analysis for Enterococcus faecium. All isolates were tested for the presence of mutations or genes encoding linezolid resistance.ResultsIn total 99% of the VRE and VVE isolates were E. faecium. From 2015 through 2019, 91.1% of the VRE and VVE were vanA E. faecium. During 2020, to the number of vanB E. faecium increased to 254 of 509 VRE and VVE isolates. Between 2015 and 2022, seven E. faecium clusters dominated: ST80-CT14 vanA, ST117-CT24 vanA, ST203-CT859 vanA, ST1421-CT1134 vanA (VVE cluster), ST80-CT1064 vanA/vanB, ST117-CT36 vanB and ST80-CT2406 vanB. We detected 35 linezolid vancomycin-resistant E. faecium and eight linezolid-resistant VVEfm.ConclusionFrom 2015 to 2022, the numbers of VRE and VVE increased. The spread of the VVE cluster ST1421-CT1134 vanA E. faecium in Denmark is a concern, especially since VVE diagnostics are challenging. The finding of LVRE, although in small numbers, ia also a concern, as treatment options are limited.

VirulenceFinder for Enterococcus faecium and Enterococcus lactis: an enhanced database for detection of putative virulence markers by using whole-genome sequencing data.

Enterococcus faecium (Efm) is a leading cause of hospital-associated (HA) infections, often enriched in putative virulence markers (PVMs). Recently, the Efm clade B was assigned as Enterococcus lactis (Elts), which usually lack HA-Efm infection markers. Available databases for extracting PVM are incomplete and/or present an intermix of genes from Efm and Enterococcus faecalis, with distinct virulence profiles. In this study, we constructed a new database containing 27 PVMs [acm, scm, sgrA, ecbA, fnm, sagA, hylEfm, ptsD, orf1481, fms15, fms21-fms20 (pili gene cluster 1, PGC-1), fms14-fms17-fms13 (PGC-2), empA-empB-empC (PGC-3), fms11-fms19-fms16 (PGC-4), ccpA, bepA, gls20-glsB1, and gls33-glsB] from nine reference genomes (seven Efm + two Elts). The database was validated against these reference genomes and further evaluated using a collection of well-characterized Efm (n = 43) and Elts (n = 7) control strains, by assessing PVM presence/absence and its variants together with a genomic phylogeny constructed as single-nucleotide polymorphisms. We found a high concordance between the phylogeny and in silico findings of the PVM, with Elts clustering separately and mostly carrying Elts-specific PVM gene variants. Based on our validation results, we recommend using the database with raw reads instead of assemblies to avoid missing gene variants. This newly constructed database of 27 PVMs will enable a more comprehensive characterization of Efm and Elts based on WGS data. The developed database exhibits scalability and boasts a range of applications in public health, including diagnostics, outbreak investigations, and epidemiological studies. It can be further used in risk assessment for distinguishing between safe and unsafe enterococci.IMPORTANCEThe newly constructed database, consisting of 27 putative virulence markers, is highly scalable and serves as a valuable resource for the comprehensive characterization of these closely related species using WGS data. It holds significant potential for various public health applications, including hospital outbreak investigations, surveillance, and risk assessment for probiotics and feed additives.

Perceptions of society regarding the concept of nurse: A metaphorical study.

INTRODUCTION: Metaphors are one of the most effective linguistic tools that are used to reveal how society describes nursing and what their vision of nursing is and to understand how effective the roles and responsibilities assumed by nurses in a multidisciplinary healthcare team are in protecting and maintaining the health of individuals, families, and society. AIM: The aim of this study was to reveal the perceptions of society about "nurses" through metaphors. METHODS: The study was planned with a mixed design involving qualitative and quantitative research methods. It was carried out with 810 people living in Turkey who were between the ages of 15 and 65 and voluntarily participated in the study. Each participant was asked to fill in the blanks in the sentence, "A nurse is like a/an………………because…………" The data were analyzed by using qualitative (content analysis) and quantitative (chi-squared) data analysis methods. RESULTS: It was determined that the participants produced 194 metaphors related to the concept of a "nurse." It was observed that they frequently used metaphors of "angel," "parent," "doctor's assistant/right hand," "lifesaver," and "confidant" regarding the concept of nurse and conceptualized a nurse as "Beneficial/Helpful/Healer/Facilitator." CONCLUSIONS AND CLINICAL RELEVANCE: The results showed that the awareness and perception of society toward nurses should be improved on the basis of the opportunity created by the COVID-19 pandemic period, and the concepts should be introduced to younger generations in a wider framework under the leadership of nursing faculties.

Do the Lifelong Learning Tendencies of Nursing Students Affect Their Attitudes Toward E-Learning?

AIM: This study aimed to determine the lifelong learning tendencies and e-learning attitudes of prospective nurses and the relationship between these variables. METHOD: This was a descriptive study conducted to find the relationship between lifelong learning tendencies and e-learning attitudes of nurses. The population of the study consisted of a total of 1202 students who were enrolled in the nursing faculty of a state university. The data were collected by an information form, the Lifelong Learning Tendency Scale, and the E-Learning Attitude Scale. The study was conducted between April and May 2018. Continuous variables were presented as arithmetic means, standard deviations, and minimum, maximum, and median values, while categorical variables were presented as frequencies and percentages. Pearson correlation test was used to determine the relationship between the scores of the scales. RESULTS: The minimum score of the nursing students was 70.00 and their maximum scores was 152.00 in the Lifelong Learning Tendency Scale, with a mean score of 122.80 ± 21.35. The minimum score of the participants was 34.00 and their maximum score was 95.00 in the E-Learning Attitude Scale, with a mean score of 62.56 ± 8.72. There was a positive and weak statistically significant relationship between the lifelong learning tendencies and e-learning attitudes of the prospective nurses (r = .238, p > .01). CONCLUSION: As a result of the study, the lifelong learning tendencies of the nursing students were found to be high, and considering the subdimension scores of lifelong learning tendency scale of the nursing students, in general, the participants' motivation, persistence, and deficiency in learning scores were high and curiosity motivation scores were medium. They had medium-level attitudes toward e-learning, and there was a weak, positive relationship between their lifelong learning tendencies and e-learning attitudes. It is recommended that involving nursing students in seminars, conferences, and scientific activities will support their lifelong learning. It is also recommended to organize learning environments where they will experience positive e-learnings.

The Relationship Between Learning Needs and Fatalism Tendency in Women Who Have a Relative with Breast Cancer.

The aim of this study was to determine the information-support needs and level of meeting these needs, the tendency of fatalism trend, and the relationship between these parameters in women having a relative with breast cancer. The research was carried out with 400 women who were the primary relatives of patients treated within oncology units. Participants completed an information form, the information support needs questionnaire and the fatalism tendency scale. There was found to be a high, negative and weak significant relationship between the mean of needs for information-support and the mean of fatalism tendency scale (r = - 343; p < .001) and high, negative and average significant relationship with fulfilling their needs. There was also a negative relationship between the importance for information-support needs, fulfilling their needs and fatalism tendency in women who have relatives with breast cancer.

Transmission of Antimicrobial-Resistant Staphylococcus aureus Clonal Complex 9 between Pigs and Humans, United States.

Transmission of livestock-associated Staphylococcus aureus clonal complex 9 (LA-SA CC9) between pigs raised on industrial hog operations (IHOs) and humans in the United States is poorly understood. We analyzed whole-genome sequences from 32 international S. aureus CC9 isolates and 49 LA-SA CC9 isolates from IHO pigs and humans who work on or live near IHOs in 10 pig-producing counties in North Carolina, USA. Bioinformatic analysis of sequence data from the 81 isolates demonstrated 3 major LA-SA CC9 clades. North Carolina isolates all fell within a single clade (C3). High-resolution phylogenetic analysis of C3 revealed 2 subclades of intermingled IHO pig and human isolates differing by 0-34 single-nucleotide polymorphisms. Our findings suggest that LA-SA CC9 from pigs and humans share a common source and provide evidence of transmission of antimicrobial-resistant LA-SA CC9 between IHO pigs and humans who work on or live near IHOs in North Carolina.

Complete Genome Sequences of Methicillin-Resistant Staphylococcus aureus Strains 110900 and 128254, Two Representatives of the CRISPR-Cas-Carrying Sequence Type 630/spa Type t4549 Lineage.

Methicillin-resistant Staphylococcus aureus (MRSA) sequence type 630 (ST630) and spa type t4549 is an emerging lineage in Nordic countries, and some representatives carry the CRISPR-Cas system. Here, the complete genome sequences of two isolates from this lineage are presented, comprising chromosomes of 2,918,239 and 2,877,083 nucleotides, respectively, and a 2,473-nucleotide plasmid carrying erm(C).

Molecular characterization of Danish ESBL/AmpC-producing Klebsiella pneumoniae from bloodstream infections, 2018.

OBJECTIVES: The aim of the study was to molecularly characterize third-generation cephalosporin-resistant Klebsiella pneumoniae isolated from bloodstream infections in Denmark in 2018 using whole-genome sequencing (WGS) data, and to compare these isolates to the most common clones detected in 2006 and 2008. METHODS: Sixty-two extended-spectrum beta-lactamase (ESBL)/AmpC-producing K. pneumoniae isolates from Danish blood cultures from 2018 were analysed using WGS to obtain multilocus sequence typing (MLST), core genome MLST (cgMLST), resistance profile and phylogeny. These were compared to the most common ESBL K. pneumoniae clones detected in 2006 and 2008. RESULTS: The most common ESBL clone was ST15 CTX-M-15, the DHA-1 enzyme was the most common in AmpC isolates, and the OXA-48-like group was the most common carbapenemase. Thirty-nine different sequence types (STs) were found, with the most frequent being ST14, ST15 and ST37, accounting for 24% of the isolates. The isolates were subdivided into 55 complex types (CTs) of which 49 were singletons, with the most frequent being ST14-CT2080. Two of the CTX-M-15-producing isolates from 2018 belonged to the ST15-CT105/CT3078 clone, which was first detected in 2006. CONCLUSIONS: The ESBL/AmpC K. pneumoniae isolates detected in Danish blood cultures belonged to many different types. No dominant clones were circulating in Danish hospitals, but the ST15-CT105/CT3078 CTX-M-15 K. pneumoniae clone was seen 13 years after its first detection.

Surveillance of OXA-244-producing Escherichia coli and epidemiologic investigation of cases, Denmark, January 2016 to August 2019.

BackgroundCarbapenemase-producing Escherichia coli are increasing worldwide. In recent years, an increase in OXA-244-producing E. coli isolates has been seen in the national surveillance of carbapenemase-producing organisms in Denmark.AimMolecular characterisation and epidemiological investigation of OXA-244-producing E. coli isolates from January 2016 to August 2019.MethodsFor the epidemiological investigation, data from the Danish National Patient Registry and the Danish register of civil registration were used together with data from phone interviews with patients. Isolates were characterised by analysing whole genome sequences for resistance genes, MLST and core genome MLST (cgMLST).ResultsIn total, 24 OXA-244-producing E. coli isolates were obtained from 23 patients. Among the 23 patients, 13 reported travelling before detection of the E. coli isolates, with seven having visited countries in Northern Africa. Fifteen isolates also carried an extended-spectrum beta-lactamase gene and one had a plasmid-encoded AmpC gene. The most common detected sequence type (ST) was ST38, followed by ST69, ST167, ST10, ST361 and ST3268. Three clonal clusters were detected by cgMLST, but none of these clusters seemed to reflect nosocomial transmission in Denmark.ConclusionImport of OXA-244 E. coli isolates from travelling abroad seems likely for the majority of cases. Community sources were also possible, as many of the patients had no history of hospitalisation and many of the E. coli isolates belonged to STs that are present in the community. It was not possible to point at a single country or a community source as risk factor for acquiring OXA-244-producing E. coli.

Association between vancomycin-resistant Enterococcus faecium colonization and subsequent infection: a retrospective WGS study.

BACKGROUND: Since 2012, the incidence of vancomycin-resistant Enterococcus faecium (VREfm) has increased dramatically in Copenhagen and vanA E. faecium has become endemic and polyclonal. OBJECTIVES: To examine whether a patient with a positive VRE clinical sample had the same VREfm in a preceding screening sample (within 60 days). METHODS: We performed a 30 month retrospective study. From our laboratory information system (LIS), we identified all patients with an invasive VREfm isolate and a VREfm rectal screening isolate within 60 days before infection. VREfm pairs (screening isolate and invasive isolate) were whole-genome sequenced. All isolates were analysed using SeqSphere and core-genome MLST (cgMLST) types were determined. We examined all isolates for the presence of the three most dominant vanA plasmids in the Capital Region of Denmark. Two novel vanA plasmids were closed by Nanopore/Illumina sequencing. RESULTS: We found a total of 19 VREfm pairs. Of these, 13 patients had pairs with matching cgMLST types and vanA plasmids and a median number of 6 days from identification of carriage to clinical infection. One patient had a pair with non-matching cgMLST types but matching vanA plasmids and 24 days between identification of carriage to clinical infection. Five patients had pairs with non-matching cgMLST types and non-matching vanA plasmids and a median number of 18 days from identification of carriage to clinical infection. CONCLUSIONS: Of our 19 pairs, 13 were a match regarding cgMLST types (68%) and 1 more (5%) had matching vanA plasmids. Infection was thus preceded by colonization with the same isolates in 13 out of 19 patients. The five mismatches (26%) could be explained by the longer interval between colonization and infection.

A valid and reliable tool in assessing patient education: the Patient Education Implementation Scale.

AIM: This study aimed to develop a valid and reliable tool for assessing the frequency of nurses' implementation of patient education in line with the stages of determining needs, assessment and planning, implementation, and evaluation and documentation. BACKGROUND: Patient education is important in terms of the patient's completion of a reliable and effective treatment process. Patient education is one of the main responsibilities of a nurse. No valid and reliable study that assessed nurses' patient education process implementation was found in the literature. METHODS: This instrument development study was conducted with 583 nurses working at university, private, and research and training hospitals located in the province of Istanbul in Turkey. The items of the Patient Education Implementation Scale were developed in line with the literature and expert opinions. The analyses involved descriptive statistics and psychometric analyses. The level of statistical significance was accepted as P < .05. RESULTS: The content validity index was calculated as 0.96 for the 42-item Patient Education Implementation Scale, which explained 63.37% of the total variance. The scale items whose factor loads were 0.45 or higher were divided into four factors as (a) determining education needs, (b) assessment and planning, (c) implementation, and (d) evaluation and documentation. The Cronbach's alpha coefficients were 0.78-0.95 for the subdimensions and 0.97 for the general scale. CONCLUSION: It was determined that the Patient Education Implementation Scale is a valid and reliable tool.

Genome wide association study of 5 agronomic traits in olive (Olea europaea L.).

Olive (Olea europaea L.) is one of the most economically and historically important fruit crops worldwide. Genetic progress for valuable agronomic traits has been slow in olive despite its importance and benefits. Advances in next generation sequencing technologies provide inexpensive and highly reproducible genotyping approaches such as Genotyping by Sequencing, enabling genome wide association study (GWAS). Here we present the first comprehensive GWAS study on olive using GBS. A total of 183 accessions (FULL panel) were genotyped using GBS, 94 from the Turkish Olive GenBank Resource (TOGR panel) and 89 from the USDA-ARS National Clonal Germplasm Repository (NCGR panel) in the USA. After filtering low quality and redundant markers, GWAS was conducted using 24,977 SNPs in FULL, TOGR and NCGR panels. In total, 52 significant associations were detected for leaf length, fruit weight, stone weight and fruit flesh to pit ratio using the MLM_K. Significant GWAS hits were mapped to their positions and 19 candidate genes were identified within a 10-kb distance of the most significant SNP. Our findings provide a framework for the development of markers and identification of candidate genes that could be used in olive breeding programs.

Author Correction: Comparison of livestock-associated and community-associated Staphylococcus aureus pathogenicity in a mouse model of skin and soft tissue infection.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Surveillance of vancomycin-resistant enterococci reveals shift in dominating clones and national spread of a vancomycin-variable vanA Enterococcus faecium ST1421-CT1134 clone, Denmark, 2015 to March 2019.

We describe clonal shifts in vanA Enterococcus faecium isolates from clinical samples obtained from patients in Denmark from 2015 to the first quarter (Q1) of 2019. During Q1 2019, the vancomycin-variable enterococci (VVE) ST1421-CT1134 vanA E. faecium became the most dominant vanA E. faecium clone and has spread to all five regions in Denmark. Among 174 E. faecium isolates with vanA, vanB or vanA/vanB genes in Q1 2019, 44% belonged to this type.

Comparison of livestock-associated and community-associated Staphylococcus aureus pathogenicity in a mouse model of skin and soft tissue infection.

Industrial hog operation (IHO) workers are at increased risk of carrying Staphylococcus aureus in their nares, particularly strains that are livestock-associated (LA) and multidrug-resistant. The pathogenicity of LA-S. aureus strains remains unclear, with some prior studies suggesting reduced transmission and virulence in humans compared to community-associated methicillin-resistant (CA-MRSA) S. aureus. The objective of this study was to determine the degree to which LA-S. aureus strains contracted by IHO workers cause disease relative to a representative CA-MRSA strain in a mouse model of skin and soft tissue infection (SSTI). Mice infected with CC398 LA-S. aureus strains (IHW398-1 and IHW398-2) developed larger lesion sizes with higher bacterial burden than mice infected with CA-MRSA (SF8300) (p < 0.05). The greatest lesion size and bacterial burden was seen with a CC398 strain that produced a recurrent SSTI in an IHO worker. The LA-S. aureus infected mice had decreased IL-1ß protein levels compared with CA-MRSA-infected mice (p < 0.05), suggesting a suboptimal host response to LA-S. aureus SSTIs. WGSA revealed heterogeneity in virulence factor and antimicrobial resistance genes carried by LA-S. aureus and CA-MRSA strains. The observed pathogenicity suggest that more attention should be placed on preventing the spread of LA-S. aureus into human populations.

LRE-Finder, a Web tool for detection of the 23S rRNA mutations and the optrA, cfr, cfr(B) and poxtA genes encoding linezolid resistance in enterococci from whole-genome sequences.

OBJECTIVES: In enterococci, resistance to linezolid is often mediated by mutations in the V domain of the 23S rRNA gene (G2576T or G2505A). Furthermore, four genes [optrA, cfr, cfr(B) and poxtA] encode linezolid resistance in enterococci. We aimed to develop a Web tool for detection of the two mutations and the four genes encoding linezolid resistance in enterococci from whole-genome sequence data. METHODS: LRE-Finder (where LRE stands for linezolid-resistant enterococci) detected the fraction of Ts in position 2576 and the fraction of As in position 2505 of the 23S rRNA and the cfr, cfr(B), optrA and poxtA genes by aligning raw sequencing reads (fastq format) with k-mer alignment. For evaluation, fastq files from 21 LRE isolates were submitted to LRE-Finder. As negative controls, fastq files from 1473 non-LRE isolates were submitted to LRE-Finder. The MICs of linezolid were determined for the 21 LRE isolates. As LRE-negative controls, 26 VRE isolates were additionally selected for linezolid MIC determination. RESULTS: LRE-Finder was validated and showed 100% concordance with phenotypic susceptibility testing. A cut-off of 10% mutations in position 2576 and/or position 2505 was set in LRE-Finder for predicting a linezolid resistance phenotype. This cut-off allows for detection of a single mutated 23S allele in both Enterococcus faecalis and Enterococcus faecium, while ignoring low-level sequencing noise. CONCLUSIONS: A Web tool for detection of the 23S rRNA mutations (G2576T and G2505A) and the optrA, cfr, cfr(B) and poxtA genes from whole-genome sequences from enterococci is now available online.

The relationship between critical thinking and emotional intelligence in nursing students: A longitudinal study.

BACKGROUND: Emotional Intelligence and critical thinking are regarded as important traits that nurses have which may influence the quality of their work including clinical decision-making and reasoning ability and adoption of evidence-based practice and practice-based knowledge. OBJECTIVES: The aim of this study is to investigate nursing students' critical thinking dispositions and emotional intelligence as an essential skill, over the course of the undergraduate nursing program. DESIGN: A longitudinal design. SETTING AND PARTICIPANTS: The research study was conducted as a longitudinal design. The target group of this study consists of 182 students studying at the faculty of nursing. Asymmetrical cluster sampling method has been applied to select the sample group and all students in their first academic year were included in the study. METHOD: Information Form, California Critical Thinking Disposition Scale and Emotional Intelligence Assessment Scale were used in order to collect data. The data was analyzed by using frequency, standard deviation, Kruskal Wallis and Bonferroni test. RESULTS: There was no relationship between sub-dimensions of emotional intelligence respectively; awareness of emotions, empathy, social skills in the first academic year and critical thinking disposition and the end of academic year. A moderate correlation was found in the positive direction between the self-motivation at the beginning of the academic year and critical thinking disposition at the end of the final academic year. CONCLUSION: It is recommended that the nursing scholarship investigates the current issues on the subjects of emotional intelligence and critical thinking in detail, discuss different aspects of the subjects and debate over the criticisms. Briefly, the discussion should go beyond the scope of nursing and include different aspects.

SCCmecFinder, a Web-Based Tool for Typing of Staphylococcal Cassette Chromosome mec in Staphylococcus aureus Using Whole-Genome Sequence Data.

Typing of methicillin-resistant Staphylococcus aureus (MRSA) is important in infection control and surveillance. The current nomenclature of MRSA includes the genetic background of the S. aureus strain determined by multilocus sequence typing (MLST) or equivalent methods like spa typing and typing of the mobile genetic element staphylococcal cassette chromosome mec (SCCmec), which carries the mecA or mecC gene. Whereas MLST and spa typing are relatively simple, typing of SCCmec is less trivial because of its heterogeneity. Whole-genome sequencing (WGS) provides the essential data for typing of the genetic background and SCCmec, but so far, no bioinformatic tools for SCCmec typing have been available. Here, we report the development and evaluation of SCCmecFinder for characterization of the SCCmec element from S. aureus WGS data. SCCmecFinder is able to identify all SCCmec element types, designated I to XIII, with subtyping of SCCmec types IV (2B) and V (5C2). SCCmec elements are characterized by two different gene prediction approaches to achieve correct annotation, a Basic Local Alignment Search Tool (BLAST)-based approach and a k-mer-based approach. Evaluation of SCCmecFinder by using a diverse collection of clinical isolates (n = 93) showed a high typeability level of 96.7%, which increased to 98.9% upon modification of the default settings. In conclusion, SCCmecFinder can be an alternative to more laborious SCCmec typing methods and is freely available at https://cge.cbs.dtu.dk/services/SCCmecFinder. IMPORTANCE SCCmec in MRSA is acknowledged to be of importance not only because it contains the mecA or mecC gene but also for staphylococcal adaptation to different environments, e.g., in hospitals, the community, and livestock. Typing of SCCmec by PCR techniques has, because of its heterogeneity, been challenging, and whole-genome sequencing has only partially solved this since no good bioinformatic tools have been available. In this article, we describe the development of a new bioinformatic tool, SCCmecFinder, that includes most of the needs for infection control professionals and researchers regarding the interpretation of SCCmec elements. The software detects all of the SCCmec elements accepted by the International Working Group on the Classification of Staphylococcal Cassette Chromosome Elements, and users will be prompted if diverging and potential new elements are uploaded. Furthermore, SCCmecFinder will be curated and updated as new elements are found and it is easy to use and freely accessible.

The attitudes of emergency department nurses towards patient safety.

This research was planned to identify the attitudes of emergency department nurses towards patient safety. The study was performed as descriptive. The universe of the research the universe comprised hospitals defined as 3rd level according to Turkish health care classification, which provides service to all health disciplines in Istanbul. The sample consisted of emergency department (ED) nurses who work in those hospitals. The data was collected by using tools such as the "Information Questionnaire" and the "Patient Safety Attitudes Scale". In this study, the attitudes of ED nurses towards patient safety were found to be average and was not related to age, gender, education level, nursing experience, ED experience, ED certification, patient safety training, nurse's self sufficiency perception of patient safety, hospital's quality certification or ED quality certification. The attitudes of nurses towards patient safety were compared by age, gender, marital status, education level, ED experience and there was no meaningful difference. However, a meaningful difference was found between the age groups and the "defining stress" sub-dimension of the Patient Safety Attitudes Scale. ED nurses' status of certification for emergency care, patient safety training, training of quality, hospitals' or ED's quality certification status had no significant statistical difference.

RUCS: rapid identification of PCR primers for unique core sequences.

MOTIVATION: Designing PCR primers to target a specific selection of whole genome sequenced strains can be a long, arduous and sometimes impractical task. Such tasks would benefit greatly from an automated tool to both identify unique targets, and to validate the vast number of potential primer pairs for the targets in silico. RESULTS: Here we present RUCS, a program that will find PCR primer pairs and probes for the unique core sequences of a positive genome dataset complement to a negative genome dataset. The resulting primer pairs and probes are in addition to simple selection also validated through a complex in silico PCR simulation. We compared our method, which identifies the unique core sequences, against an existing tool called ssGeneFinder, and found that our method was 6.5-20 times more sensitive. We used RUCS to design primer pairs that would target a set of genomes known to contain the mcr-1 colistin resistance gene. Three of the predicted pairs were chosen for experimental validation using PCR and gel electrophoresis. All three pairs successfully produced an amplicon with the target length for the samples containing mcr-1 and no amplification products were produced for the negative samples. The novel methods presented in this manuscript can reduce the time needed to identify target sequences, and provide a quick virtual PCR validation to eliminate time wasted on ambiguously binding primers. AVAILABILITY AND IMPLEMENTATION: Source code is freely available on https://bitbucket.org/genomicepidemiology/rucs. Web service is freely available on https://cge.cbs.dtu.dk/services/RUCS. CONTACT: mcft@cbs.dtu.dk. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.