Maltreatment-related childhood adversity is the leading preventable risk factor for mental illness and substance abuse. Although the association between maltreatment and psychopathology is compelling, there is a pressing need to understand how maltreatment increases the risk of psychiatric disorders. Emerging evidence suggests that maltreatment alters trajectories of brain development to affect sensory systems, network architecture and circuits involved in threat detection, emotional regulation and reward anticipation. This Review explores whether these alterations reflect toxic effects of early-life stress or potentially adaptive modifications, the relationship between psychopathology and brain changes, and the distinction between resilience, susceptibility and compensation.

The literature suggests that smart pumps reduce but do not eliminate programming errors. Although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were still not as effective as hard limits because of high override rates. Compliance in using smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug libraries, developing standardized drug libraries, decreasing the number of unnecessary warnings, and developing stronger approaches to minimize workarounds. Also, as with other clinical information systems, smart pumps should be implemented with the idea of using continuous quality improvement processes to iteratively improve their use.

Background Childhood abuse is a major risk factor for psychopathology. Previous studies have identified brain differences in maltreated individuals but have not focused on potential differences in network architecture. Methods High-resolution T1-weighted MRI scans were obtained from 265 unmedicated, right-handed 18-25-year-olds who were classified as maltreated (n=142, 55M/87F) or non-maltreated (n=123, 46M/77F) based on extensive interviews. Cortical thickness was assessed in 112 cortical regions (nodes) and inter-regional partial correlations across subjects were calculated to derive the lowest equivalent cost single-cluster group networks. Permutation tests were used to ascertain whether maltreatment was associated with significant alterations in key centrality measures of these regions and membership in the highly interconnected ‘rich club’. Results Marked differences in centrality (connectedness, ‘importance’) were observed in a handful of cortical regions. Left anterior cingulate had the second highest number of connections (degree centrality) and was a component of the ‘rich club’ in the control network but ranked low in connectedness (106th of 112 nodes) in the network derived from maltreated-subjects (p<0.01). Conversely, right precuneus and right anterior insula ranked first and 15th in degree centrality in the maltreated network versus 90th (p=0.01) and 105th (p<0.03) in the control network. Conclusions Maltreatment was associated with decreased centrality in regions involved in emotional regulation and ability to accurately attribute thoughts or intentions to others and with enhanced centrality in regions involved in internal emotional perception, self-referential thinking and self-awareness. This may provide a potential mechanism for how maltreatment increases risk for psychopathology.

The vestibular nerves are known to influence neuronal circuits in the medullary cardiovascular areas and, through the cerebellar vermis, the basal ganglia and the limbic system. By means of noisy galvanic vestibular stimulation (GVS), it might be possible to ameliorate blunted responsiveness of degenerated neuronal circuits of patients with multi system atrophy or Parkinson's disease, or both. We evaluated the effect of 24-hour noisy GVS on long-term heart rate dynamics in 7 patients with multi system atrophy and on daytime trunk activity dynamics in 12 patients with either levodopa-responsive Parkinson's disease or levodopa-unresponsive parkinsonism. Six of the latter patients were also examined for cognitive performance by means of a continuous performance test. Short-range or high-frequency fluctuations of heart rate were significantly increased by the noisy GVS compared with sham stimulation, suggestive of improved autonomic, especially parasympathetic, responsiveness. Long-range antipersistency of trunk activity patterns probed by an autocorrelation measure was significantly increased by the noisy GVS, suggestive of quickening of bradykinesic rest-to-active transitions. The mean reaction time of the continuous performance test was also significantly decreased by the noisy GVS, without significant changes in either the omission or commission error ratios, which is suggestive of improved motor execution during the cognitive task. In conclusion, the noisy GVS is effective in boosting the neurodegenerative brains of patients with multi system atrophy or Parkinson's disease, or both, including those unresponsive to standard levodopa therapy; it is also effective in improving these patients' autonomic and motor responsiveness.

We implemented a web-based, patient-centered toolkit that engages patients/caregivers in the hospital plan of care by facilitating education and patient-provider communication. Of the 585 eligible patients approached on medical intensive care and oncology units, 239 were enrolled (119 patients, 120 caregivers). The most common reason for not approaching the patient was our inability to identify a health care proxy when a patient was incapacitated. Significantly more caregivers were enrolled in medical intensive care units compared with oncology units (75% vs 32%; P < .01). Of the 239 patient/caregivers, 158 (66%) and 97 (41%) inputted a daily and overall goal, respectively. Use of educational content was highest for medications and test results and infrequent for problems. The most common clinical theme identified in 291 messages sent by 158 patients/caregivers was health concerns, needs, preferences, or questions (19%, 55 of 291). The average system usability scores and satisfaction ratings of a sample of surveyed enrollees were favorable. From analysis of feedback, we identified barriers to adoption and outlined strategies to promote use.

The hippocampus is a highly stress susceptible structure and hippocampal abnormalities have been reported in a host of psychiatric disorders including major depression and post-traumatic stress disorder (PTSD). The hippocampus appears to be particularly susceptible to early life stress with a graded reduction in volume based on number of types (multiplicity) or severity of maltreatment. We assessed whether the most important predictors of adult hippocampal volume were multiplicity, severity or duration of exposure or timing of maltreatment during developmental sensitive periods. 3T MRIs were collected on 336 unmedicated, right-handed subjects (132M/204F, 18-25 years). Exposure to broad categories of abuse and neglect during each year of childhood were assessed using the Maltreatment and Abuse Chronology of Exposure scale and evaluated using artificial intelligence and predictive analytics. Male hippocampal volume was predicted by neglect, but not abuse, up through 7 years of age. Female hippocampal volume was predicted by abuse, but not neglect, at 10, 11, 15 and 16 years. Exposure at peak age had greater predictive importance than multiplicity, severity or duration. There were also marked gender differences in subfields and portions (head, body or tail) affected by exposure. History and symptoms of major depression, PTSD or anxiety disorders were not predictive of hippocampal volume once maltreatment was accounted for. Neglect appears to foster inadequate hippocampal development in males while abuse appears to produce a stress-related deficit in females. Studies assessing hippocampal volume in psychiatric disorders need to control for the gender-specific effects of abuse and neglect.

Background: Childhood maltreatment is a major risk factor for psychopathology. However, some maltreated individuals appear remarkably resilient to the psychiatric effects while manifesting the same array of brain abnormalities as maltreated individuals with psychopathology. Hence, a critical aim is to identify compensatory brain alterations that enable resilient individuals to maintain mental well-being despite alterations in stress-susceptible regions.Method: Network models were constructed from diffusion tensor imaging and tractography in physically healthy unmedicated 18-25-year-olds (n=342, n=192 maltreated) to develop network based explanatory models.Results: First, we determined that susceptible and resilient individuals had the same alterations in global fiber stream network architecture using two different definitions of resilience (i.e., 1 -no lifetime history of Axis I or II disorders, 2 -no clinically significant symptoms of anxiety, depression, anger-hostility or somatization). Second, we confirmed an a priori hypothesis that right amygdala nodal efficiency was lower in asymptomatic resilient than in susceptible participants or controls. Third, we identified 8 other nodes with reduced nodal efficiency in resilient individuals and showed that nodal efficiency moderated the relationship between maltreatment and psychopathology. Fourth, we found that models based on global network architecture and nodal efficiency could delineate group membership (control, susceptible, resilient) with 75%, 82% and 80% cross-validated accuracy.Conclusions: Together these findings suggest that sparse fiber networks with increased smallworldness following maltreatment render individuals vulnerable to psychopathology if *

Objective:this study developed a people-centered care (PCC) partnership model for the aging society to address the challenges of social changes affecting people’s health and the new role of advanced practice nurses to sustain universal health coverage. Method:a people-centered care partnership model was developed on the basis of qualitative meta-synthesis of the literature and assessment of 14 related projects. The ongoing projects resulted in individual and social transformation by improving community health literacy and behaviors using people-centered care and enhancing partnership between healthcare providers and community members through advanced practice nurses. Results:people-centered care starts when community members and healthcare providers foreground health and social issues among community members and families. This model tackles these issues, creating new values concerning health and forming a social system that improves quality of life and social support to sustain universal health care through the process of building partnership with communities. Conclusion:a PCC partnership model addresses the challenges of social changes affecting general health and the new role of advanced practice nurses in sustaining UHC.