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Refractory subhemispheric epilepsy has been traditionally treated by resection. The last few decades have seen the emergence of disconnective techniques, for both hemispheric and subhemispheric disease. The aim of this study was to describe the technique for a disconnective surgery for large epileptogenic lesions involving the central (perirolandic cortices), parietal, and occipital lobes. This junctional cortex within the hemisphere (in contrast to anterior and posterior quadrantotomies) presents unique challenges when contemplating a complete disconnection of the region. The surgical technique is achieved through six distinct steps: fronto-central, inferior frontoparietal, lateral temporo-occipital, medial frontal, basal temporo-occipital, and posterior parasagittal callosal disconnections. The functional neuroanatomy of each step is described, along with cadaveric dissections. The authors describe this technique and include a case description of a young girl who presented with childhood-onset intractable epilepsy associated with cognitive stagnation. The postoperative seizure outcome in this patient remains excellent at 2 years’ follow-up, with gains in cognition and behavior. Excellent seizure outcomes can be achieved if the network encompassing the entire epileptogenic cortex is disconnected while ensuring preservation of fiber systems that link functionally eloquent uninvolved cortices adjacent to the central quadrant.

Nursing students must gain experience collaborating with other members of the health-care team. Simulation can provide intra- and interprofessional collaboration experience; however, there can be barriers such as scheduling difficulties. We evaluated multi-patient, standardized patient simulations using telehealth as a strategy to provide baccalaureate nursing students with opportunities to learn and practice intra- and interprofessional collaboration. Forty-four final-semester nursing students participated. Student groups rotated to the simulation laboratory over 12 weeks to participate in two simulations that used telehealth to enable them to communicate patient concerns to other clinicians: a nurse practitioner, respiratory therapists, and social workers. Self-reported collaborative competencies and amount of collaboration in the clinical setting were measured at the start and end of the semester. Satisfaction and self-confidence were measured immediately after each simulation. For collaborative competencies, there was a statistically significant improvement in all item, subscale, and overall scale mean scores. Amount of clinical collaboration significantly improved, with the amount who indicated they never reported a patient concern to another professional decreasing from 39.5% to 6.8%. Findings also revealed a high level of student satisfaction and self-confidence following the simulations. Using telehealth to collaborate during simulations is a promising strategy to prepare nursing students for practice by improving collaborative competencies and encouraging more collaboration in the clinical setting.

While distractions and interruptions are leading causes of errors during medication preparation, most nursing students are not taught how to manage distractions in a highly-interruptive environment. To help prepare nursing students to manage distractions and interruptions in clinical practice, we developed, implemented, and evaluated a medication preparation distraction and interruption simulation.To explore student and simulation facilitators experiences and perceptions of a distraction and interruption simulation.A sequential explanatory mixed-methods design was adopted including surveys, interviews, and focus groups.A mid-sized research intensive western Canadian university.A total of 112 third year nursing students who engaged in the distraction and interruption simulation, and five simulation facilitators who facilitated the distraction and interruption simulation, participated in this study.Students were invited to complete a cross sectional survey following the distraction and interruption simulation and were then invited to participate in focus groups. Simulation facilitators were invited to participate in one-on-one interviews following facilitating the distraction and interruption simulation. All data were collected between June and December 2020.Data from surveys, interviews, and focus groups were delineated into 4 themes related to the phases of the simulation. The prebriefing provided an overview of the simulation and helped create psychological safety that was imperative for learning about potential medication errors when being distracted and interrupted. The simulation scenario had a high degree of fidelity and helped students implement strategies to manage distractions and interruptions. The structured debrief provided an opportunity for meaningful reflection. The impact of the simulation was apparent as students articulated the balance between speed versus safety and new strategies developed to manage distractions and interruptions in clinical practice.This study supports the use of simulation to develop key skills for managing distractions and interruptions during medication preparation in clinical practice.

Background Nurse faculty must utilize teaching strategies that promote student achievement of essential competencies, and simulation can provide experiential learning to help prepare students for professional practice. Purpose The purpose of this phenomenological qualitative study was to explore baccalaureate nursing students' experiences with multi-patient, standardized patient simulations that used telehealth to provide opportunities to learn and practice intra- and interprofessional collaboration. Student perceptions of their ability to utilize lessons from the simulations in clinical practice were also examined. Methods Focus group interviews were conducted with 27 final-semester baccalaureate nursing students after they had participated in two telehealth-enhanced simulations. Results Analysis revealed five themes: Anxiety due to lack of experience, Improved clinical reasoning, Real world practice, How to communicate effectively, and Application to clinical practice. Conclusion The use of telehealth helped overcome barriers to implementing collaborative simulations and provided students with experiential learning that addressed essential competencies for safe and effective professional nursing practice.

Issues related to elder abuse, including research, prevention, and treatment are addressed in the USA by several federal agencies, at the state level, and in over 3000 counties across the 50 states. Numerous nonprofit and professional organizations work to provide information and services designed to prevent elder abuse and to assist the victims. Although each organization plays an important role, minimal levels of funding restrict what can be accomplished. There is limited coordination across agencies, and accordingly there are gaps and duplication of efforts. In 2011, the US Government Accountability Office issued a report entitled: “Stronger Federal Leadership Could Enhance National Response to Elder Abuse”. Most states in the USA have mandatory reporting laws, which require such entities as banks or physicians to report instances of abuse to an official agency or to the police. Federal agencies involved in elder abuse issues include the Administration on Aging, which funds the National Center on Elder Abuse and sponsors other programs and seminars, and the National Institute of Justice which is interested in the extent to which elder abuse represents criminal activity and funds several research projects. The Center for Disease Control publishes a fact sheet and reports on the topic. The Long-Term Care Ombudsman Program under the Department of Health and Human Services responds to the issues of alleged abuse in nursing homes and inspects nursing homes on a regular basis. Among private nonprofit agencies, the National Committee for the Prevention of Elder Abuse (NCPEA) unites researchers, practitioners, educators, and advocates to work toward preventing elder abuse. Virtually, every county in the USA has an adult protective services agency, which takes reports of elder abuse and investigates them. Many of these county level agencies belong to a national organization, the National Adult Protective Services Association. This chapter describes the activities of these various organizational entities, both federal and nonfederal, and discusses the extent to which the GAO report has been influential in guiding current activities in the field.

This symposium begins by fist comparing features of the Japanese elder abuse prevention law to 3 other abuse prevention laws - child abuse, domestic abuse and abuse against people with disabilities. It highlights amendments that have been made to the child abuse and domestic abuse prevention laws since their enactment based on implementation experience, drawing contrast to the lack of amendments made to the elder abuse prevention law despite its three-year requirement for amendment review. Overall strengths and weaknesses of the elder abuse law are discussed including needed areas of revision. Second, a case study of nearly two decades of elder abuse prevention activities in Matsudo-city are presented and the subsequent enactment in April 2020 of a new regulation of the city is discussed. In addition, interim outcomes of a related research study in Matsudo-city on elder abuse involving non-caregivers for elderly people that will expand understanding of abuse prevention efforts are presented. Third, how can we abolish elder abuse in institutional settings will be discussed by analyzing elder abuse case studies. Finally, the most updated research outcomes conducted in in-home care service settings in 2020 will be presented. Its preliminary analyses revealed out of 1,417 responses, 2.9% were found to be ”body restraints.” Such abusive actions are less likely to be detected by others. The symposium concludes by assessing challenges for preventing elder abuse in policy and practice.

Background Although patients' families want to be invited to the bedside of hospitalized loved ones during crisis events, little is known about patients' perceptions of family presence. Objective To explore adult inpatients' perceptions of family presence during resuscitation, near-resuscitation, and unplanned invasive cardiac procedures shortly after the life-threatening event. Methods In this qualitative study, data were collected by interviews at least 13 hours after a crisis event and before hospital discharge. Data were audio recorded, transcribed, and analyzed for themes. Results From the bedside interviews (N = 48), the overarching theme of "being there" was explained more specifically as "being there is beneficial," "being there is hard," "families in the way," and "desire for control." Most participants preferred family presence, although preferences varied with types of crisis events, patients' predictions of family members' responses, and the nature of family relationships. New perspectives emerged about patients' decision making related to family presence. Conclusions This study extends existing knowledge about factors that influence the decision-making processes of hospitalized patients regarding family presence during a crisis event. Health care professionals can provide support as patients ponder difficult decisions about who to have present and can reduce patients' fears that families might interfere with the life-saving efforts.

Increased life expectancy has resulted in a growing number of persons over age 65, and this number continues to escalate. The increasing population of older people has led to the prediction that aging is accompanied by greater physical and mental problems that result in dependency—and also lead to situations in which elders may be mistreated. The consequences of mistreatment for elders at large, for individuals, and for society as a whole are shown in this chapter, including physical and emotional consequences as well as mortality. The lived experiences of abused elders are explored, emphasizing not only vulnerabilities but also resilience, and the need to listen to older adults and involve them in the research, planning, and evaluation of all aspects of intervention. A determinant of health framework is used to provide a comprehensive method of inquiry into this complex topic, including such important elements as gender and culture, coping skills, the role of health services, and physical, social, and legal environments.

In today's complex, chaotic, and rapidly changing healthcare environment, a newly registered nurse will face many obstacles on the journey into a professional role.

Significant developments in minimally invasive surgery (MIS) for the adult population have led to increased application of MIS techniques for pediatric patients. Laparoscopy is the most common MIS procedure used in pediatrics. Traditional surgical procedures that are now being performed laparoscopically include gastrostomy, pyloromyotomy, and repair of congenital diaphragmatic hernia and imperforate anus. All perioperative team members must be prepared to provide appropriately sized instruments and equipment to facilitate use of MIS techniques in the pediatric population and must ensure safe patient care to achieve optimal patient outcomes.

This article provides an overview of the development of a research agenda on resident-to-resident aggression (RRA) in long-term care facilities by an expert panel of researchers and practitioners. A 1-day consensus-building workshop using a modified Delphi approach was held to gain consensus on nomenclature and an operational definition for RRA, to identify RRA research priorities, and to develop a roadmap for future research on these priorities. Among the six identified terms in the literature, RRA was selected. The top five priorities were: (a) developing/assessing RRA environmental interventions; (b) identification of the environmental factors triggering RRA; (c) incidence/prevalence of RRA; (d) developing/assessing staff RRA education interventions; and (e) identification of RRA perpetrator and victim characteristics. Given the significant harm RRA poses for long-term care residents, this meeting is an important milestone, as it is the first organized effort to mobilize knowledge on this under-studied topic at the research, clinical, and policy levels.

We have measured the inhibition of the mutagenicity of the mycotoxin aflatoxin-B1 in the liver of the rat by plant material of Scutellaria baicalensis, or Huang-qin. The addition of one percent dried Huang-qin to the feed of the animals reduced the mutant frequency of a subsequent administration of aflatoxin-B1 by approximately 60 and 77%, respectively, for two different batches of the plant material. The addition of Huang-qin also increased the expression of the gene for glutathione S-transferase A5 subunit by 2.5–3.0-fold, and decreased expression of P450 cytochrome 3A2 by 1.8–2.0-fold. The greater increase of the expression of the GST gene may result in the protection shown by Huang-qin. The sensitivity of the hepatic mitochondria to swelling, a measure of the mitochondrial permeability transition, is increased significantly in animals that are on a diet containing Huang-qin. This may lead to increased sensitivity to apoptosis on treatment with toxic compounds. The two batches of Huang-qin material show differences in both chemical composition and preventive potential. This study demonstrates how a combination of generating and analysis of plant varieties together with a mammalian assay for efficacy may improve the search for better plant-based prevention of cancer initiation.

The National Elder Abuse Incidence Study (NEAIS), conducted in 1994–1999 under the sponsorship of the US Administration for Children and Families and the Administration on Aging, was designed to obtain national estimates of both reported and unreported cases of elder abuse and neglect for 1996. This article contrasts the methods and results of this study with several previous studies to assess the reasons for differences in estimates. These differences include whether the study was designed to measure prevalence or incidence, the inclusiveness of the definitions, eligible age range, and methods of data collection. Future studies should combine incidence and prevalence and incorporate a sample design that will allow estimates for several age ranges and definitional subsets to meet different public policy requirements.

Article-at-a-Glance Background Patients continue to suffer preventable harm from the omission of evidence-based therapies. To remedy this, The Joint Commission developed core measures for therapies with strong evidence and, through the Top Performer on Key Quality Measures ® program, recognize hospitals that deliver those therapies to 95% of patients. The Johns Hopkins Medicine board of trustees committed to high reliability and to providing ≥ 96% of patients with the recommended therapies. Methods The Armstrong Institute for Patient Safety and Quality coordinated the core measures initiative, which targeted nine process measures for the 96% performance goal: eight Joint Commission accountability measures and one Delmarva Foundation core measure. A conceptual model for this initiative included communicating goals, building capacity with Lean Sigma methods, transparently reporting performance and establishing an accountability plan, and developing a sustainability plan. Clinicians and quality improvement staff formed one team for each targeted process measure, and Armstrong Institute staff supported the teams' work. The primary performance measure was the percentage of patients who received the recommended process of care, as defined by the specifications for each of The Joint Commission's accountability measures. Results The ≥ 96% performance goal was achieved for 82% of the measures in 2011 and 95% of the measures in 2012. Conclusions With support from leadership and a conceptual model to communicate goals, use robust improvement methods, and ensure accountability, The Johns Hopkins Hospital achieved high reliability for The Joint Commission accountability measures.

OBJECTIVE. Cognitive impairment among the elderly has been linked to mortality in studies of clinical populations. The purpose of this study was to examine the mortality risk associated with cognitive impairment among elderly populations in the community. METHODS. Cognitive impairment and other social and health factors were assessed in 1855 elderly community residents. This sample was reinterviewed periodically to assess changes in health and survival. RESULTS. At baseline 33% of the sample were mildly impaired and 8% were severely impaired. Across a 48-month observation period the survival probability was .85 for the cognitively unimpaired, .69 for the mildly impaired, and .51 for severely impaired respondents. When adjustments were made for the effects of other health and social covariates, severely impaired persons were twice as likely to die as unimpaired persons. Those who were mildly impaired were also at an increased risk. CONCLUSIONS. Other investigators have found that cognitive impairment is a significant predictor of dementia. We found that it is a significant predictor of mortality as well. Early detection of impaired cognition and attention to associated health problems could improve the quality of life of these older adults and perhaps extend their survival.

Stability and change in patterns of health service use over a 3-year period were determined for a sample of elderly people in an urban area who claimed one of five types of health service provider as a primary source of health care—a hospital, a private physician, a network model health maintenance organization (HMO), a hospital-based group practice program (G-HMO), or a preferred provider organization (PPO). Despite certain differences in use rates for individual services, the total volume of ambulatory service use was equivalent for all five groups as was the relative rank order of use of specific ambulatory services for four of the five groups. People who claimed a hospital as their primary care source had the most unique use patterns over a full range of health care services, characterized by extremely low rates of physician visits and the highest rates of visits to hospital outpatient clinics across three time periods. G-HMO members used health-related services more frequently than did all others. PPO members, at baseline, had lower rates of total and mean hospital days than other source group members except hospital users. People who changed principal source of care during the study period were most likely to report a hospital as their care source initially. Although there is much consistency in hospital and ambulatory use across groups, the persistence of certain use patterns for members of some groups suggests that health care systems can leave an imprint on the health service use of people for whom they provide regular care.

Lack of information about medications coupled with high rates of utilization complicates compliance with medication regimens and increases the risk of adverse effects among older adults. We undertook a study of the efficacy of community-based interventions by pharmacists in a randomly-allocated one-half of a sample of 284 older adults considered to be at high risk for medication-related problems. Information and attitudes towards prescription and over-the-counter medications did not differ significantly between the intervention and comparison groups, either before or after the pharmacist interventions. However, visits to physicians were significantly less in the intervention group, suggesting an important if unexpected impact on health-related behavior.

This article compares patterns of health care utilization for hospitalizations and ambulatory care in a sample of 1855 urban, elderly, community residents who report obtaining their health care from one of four types of arrangements: a fee-for-service (FFS) physician, a hospital-based health maintenance organization, a network model HMO, or a preferred provider organization (PPO). Utilization rates reported by respondents at six month intervals over three years were adjusted for health and socioeconomic characteristics of enrollees. PPO plan members consistently have mean and total lengths of hospital stay one-third to one-half those of the others. Although rates of use of particular categories of ambulatory care vary across systems of care, total ambulatory care rates are highest for network model HMO plan members. Specific features of alternative delivery systems, rather than general model types, may have an impact on utilization rates and the costs of care.

Religious devotion is a complex phenomenon but a potentially important source of support and meaning in the lives of older adults. Nonetheless, attendance at religious services and religious preference (affiliation) have received relatively little prominence in epidemiological studies of late life mental illness despite their relative ease of measurement. We examined differences in the prevalence and course of depressive symptoms and associated characteristics among 1,855 older community residents who expressed a Jewish, Catholic, or other religious preference. At baseline, Jewish religious preference was associated with a twofold elevation in the prevalence of depressive symptoms compared to Catholics. Lack of attendance at religious services was associated with greater prevalence of depression among all groups, significantly so among Catholics. The relationship of depression with Jewish religious preference and with failure to attend services could not be accounted for by measures of age, gender, health, disability, or social support. Twenty-four months following baseline, Jewish religious preference was associated with the emergence of depressive symptoms and remained significant when the effects of age, gender, health, disability, and social support were controlled. Failure to attend services was associated with both the emergence and persistence of depression but did not remain significant once the effects of other characteristics were controlled. For both religious and health care institutions, these findings have implications for the prevention, recognition, and treatment of late life mental illness.

Objective:The objective of the study was to assess BMI and dieting attitude among high school students of selected high schools of Udupi district Materials and methods:A correlational survey design was used and samples were selected using multi stage sampling technique. Samples consisted of 200 high school students from four high schools. The analysis of the data was done using descriptive and inferential statistics. Results:The study revealed majority, 114(57%) of the samples belonged to the age group of 12-14 year,105 (52.5%) subjects were females and 69 (34.5%) students belonged to the 10th grade. The mean score of the dieting attitude was 69.68. 113 (56.5%) of the students were found to have unhealthy dieting attitude. The mean of the high school students’ BMI was 27.17 with a standard deviation of 6.45. Half , 101(50.5%) of the samples were found to be underweight. The study findings revealed that there is significant relationship between BMI and dieting attitude. A significant association was found between the class (x2=0.041), mother’s educational status (x2=0.004) and mother’s occupation (x2=0.026) with BMI at 0.05 level of significance. Gender (x2=0.028) was found to be significantly associated with the dieting attitude at 0.05 level. There was no association between dieting attitude and age. These variables were found to be independent of the dieting attitude. Conclusion :The study found that there is significant relationship between BMI and dieting attitude of high school students .Keeping in mind the findings of the study, it is recommended that periodical nutrition awareness programs be organized for the high school students.

Stability and change in the use of formal and informal social support was assessed over a three year period among a representative sample of 1855 elderly urban participants in a longitudinal study of aging and health. Whether people received informal, formal, both types of support or no support was determined in baseline, 12 and 24 month personal interviews. Most respondents retained the same form of support across all three interviews. The extent of stability or change varied according to the form of support reported at baseline. Two-thirds of those with no social support continued without support and 40% of those using both informal and formal support continued to do so at subsequent assessments. The substitution of formal for informal support was infrequent and not statistically significant. Pair wise discriminant function analyses of groups of respondents with the most frequent longitudinal support patterns were performed to identify baseline health and social characteristics associated with stable use, the addition of another form of support or change to nonuse, over time. Changes in the use of support were influenced more by initial levels of health and functional status than by social and economic circumstances. Larger proportions of respondents dropped use of support then added an additional form of support. Respondents using both formal and informal support at baseline died across time in higher proportions than those in other support categories. The extent of stability in support use and nonuse, the character of changes in support use across time and greater attrition among those who were the heaviest users of support, serve to create a relative balance in the use of informal and formal support in this aging cohort, at least over the time frame over which respondents were followed in this study.

Studies on the relationship between depression and mortality in elderly community populations have yielded contradictory findings, although an association frequently is found in studies of elderly psychiatric patients. These different results may be due to differences in the measures of depression, the populations under study, the covariates in the analysis, or to sample attrition. In this study of elderly residents of an urban neighborhood, depressive symptoms are measured at two time points. People are classified as consistently nonsymptomatic (N-N), with emergent symptoms (N-D), in remission (D-N), or persistently symptomatic (D-D). Symptoms of depression, sociodemographic characteristics, and measures of changes in health, functional status, number of chronic medical conditions, and social support are examined in relation to mortality in multivariate Cox regression models. Although symptoms of depression are not found to be related to time-to-death, older people, those with declines in health and functional status, and men have greater relative risks of mortality over a three-year follow-up.

Despite considerable progress in the epidemiology of late life depressive disorders, the determinants and course of late life depressive symptoms remain unclear. The apparent reciprocal relationship between depression and disability, a consistent finding in cross-sectional studies further confounds efforts to estimate the importance of depressive symptoms in the elderly. In a longitudinal study of 1457 aged community residents who completed the Center for Epidemiologic Studies Depression scale at baseline and 24 months later, a significant level of depressive symptoms emerged in 163 respondents (11%), while 1080 (74%) remained symptom free. Unlike other studies, we found that the number of medical conditions, social support, life events, and demographic characteristics contributed little to distinguish those with emerging symptoms from those who remained symptom free. However, increasing disability and declining health preceded the emergence of depressive symptoms and accounted for seventy percent of the variance explained by discriminant analysis. These findings have etiologic implications for both the course and determinants of depression in late life.

Over the course of a three year observation and study period, some 6% of a representative community residing urban elderly population were admitted to nursing homes. Nearly half of this group were still living in nursing homes at the end of this observation period. One third had died after entering the nursing home, and the remaining people had returned to their own homes in the community. These three groups had significantly different mean lengths of stay in nursing homes; nearly two years for those whose stays were more permanent, 50 days for those whose stays were short-term, and 153 days on average for those who died following admission. At baseline, the three groups also tended to have different patterns of health, functional and social characteristics. The short term stayers and those who died following admission to a nursing home differed from respondents who did not enter nursing homes--primarily in terms of prior living arrangements and levels of social support. The permanent stayers differed from the two other nursing home sub-groups, and from community residents, in that they tended to be older and more functionally and mentally impaired. However, at baseline they appeared at less risk to expire than those people who later died following admission to nursing homes. Clinical and research implications based on these findings are discussed.

Out-of-pocket medical expenditures were examined among a sample of 400 low-to-moderate income Medicare recipients living in the Bronx for a twelve month period in 1986-87. Using three different measures of magnitude, the most significant expenses were for Medicare and private insurance premiums, medications, and dental care. The mean percent of per capita income spent out-of-pocket for medical care (including health care premiums) was 11.0%. Elderly people who spend over 12% of their own income on medical care include those in the poorest health, those with annual incomes under $15,000, people living with spouses or others, and those using a private physician as a primary source of medical care.