Combined electroencephalography-functional magnetic resonance imaging and electrical source imaging improves localization of pediatric focal epilepsy.

OBJECTIVE: Surgical treatment in epilepsy is effective if the epileptogenic zone (EZ) can be correctly localized and characterized. Here we use simultaneous electroencephalography-functional magnetic resonance imaging (EEG-fMRI) data to derive EEG-fMRI and electrical source imaging (ESI) maps. Their yield and their individual and combined ability to (1) localize the EZ and (2) predict seizure outcome were then evaluated. METHODS: Fifty-three children with drug-resistant epilepsy underwent EEG-fMRI. Interictal discharges were mapped using both EEG-fMRI hemodynamic responses and ESI. A single localization was derived from each individual test (EEG-fMRI global maxima [GM]/ESI maximum) and from the combination of both maps (EEG-fMRI/ESI spatial intersection). To determine the localization accuracy and its predictive performance, the individual and combined test localizations were compared to the presumed EZ and to the postsurgical outcome. RESULTS: Fifty-two of 53 patients had significant maps: 47 of 53 for EEG-fMRI, 44 of 53 for ESI, and 34 of 53 for both. The EZ was well characterized in 29 patients; 26 had an EEG-fMRI GM localization that was correct in 11, 22 patients had ESI localization that was correct in 17, and 12 patients had combined EEG-fMRI and ESI that was correct in 11. Seizure outcome following resection was correctly predicted by EEG-fMRI GM in 8 of 20 patients, and by the ESI maximum in 13 of 16. The combined EEG-fMRI/ESI region entirely predicted outcome in 9 of 9 patients, including 3 with no lesion visible on MRI. INTERPRETATION: EEG-fMRI combined with ESI provides a simple unbiased localization that may predict surgery better than each individual test, including in MRI-negative patients. Ann Neurol 2017;82:278-287.

Facing the challenge of adapting to a life 'alone' in old age: the influence of losses.

AIM: The aim of this study is to explore older people's approaches to living a life characterized by losses and 'aloneness' and how this relates to loneliness. BACKGROUND: Loneliness is closely related to social status and health condition. Older people are vulnerable to experiences of loneliness due to losses, which follow the ageing process. METHOD: A qualitative interpretative design was used. Older people, aged 65 and above, living at home, in retirement villages, or in long-term care settings in Australia, Norway, and UK participated. Seventy-eight persons were included. Data were collected through open-ended interviews during autumn of 2006 and spring of 2007. The interviews were audio taped, transcribed, and analysed applying a hermeneutic, interpretative process. FINDINGS: Analyses revealed great differences in the way participants handled their life situation. Interviewees describing themselves as 'not lonely' viewed losses as normal, and they participated in meaningful activities, connected to other people and thrived in their own company. Those describing themselves as 'lonely' on the other hand, strove to create meaning in their lives, were overwhelmed by losses, had problems finding meaningful activities and difficulty keeping up social relations. CONCLUSION: Loneliness was associated with overwhelming losses, inactivity, meaninglessness, and social isolation. The contrasting findings between 'not lonely' and 'lonely' older people have implications for nursing in that nurses must seek to identify those who need help in managing their loneliness and give guidance and support. More research is needed to develop interventions that are effective in reducing loneliness.

Capacity for care: meta-ethnography of acute care nurses' experiences of the nurse-patient relationship.

AIMS: To synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings. BACKGROUND: While primary research on nurses' experiences has been reported, it has not been previously synthesized. DESIGN: Meta-ethnography. DATA SOURCES: Published literature from Australia, Europe, and North America, written in English between January 1999-October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO. REVIEW METHODS: Qualitative studies describing nurses' experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method. RESULTS: Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients. CONCLUSION: The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.

Everybody matters 3: engaging patients and relatives in decision making to promote dignity.

Practical interventions are presented around three main themes in this three part series. This third part explores "shared decision making--involve me" (Bridges et al, 2009). This recognises the importance of engaging patients, family and staff in decisions about care and treatment. The article offers a range of interventions to hear the voices of patients, staff and relatives.

Everybody matters 2: promoting dignity in acute care through effective communication.

The Dignity in Care Project (DCP) aims to deepen understanding and develop practical interventions to promote dignified care in hospitals. A key feature is that "everybody matters" (a project slogan) and that promoting and sustaining dignity in acute care requires recognition and support for staff as well as for patients and their families. DCP is a nurse led research collaboration with Royal Free Hampstead Trust, Barnet and Chase Farm Hospitals Trust and City University. Practical interventions devised by the project are presented around three keythemes. Part 1 of this series explored the first theme, "maintaining identity: see who I am", and this second part examines the second theme, "creating community: connect with me". This recognises that in the act of caring, nurses receive as well as give. Dignified care has a reciprocity where both carer and patient/family give and receive, rather than simply involving a list of practical tasks done t o someone. The third and final part looks at "shared decision making involve me" (Bridges et al, 2009).

Everybody matters. 1: How getting to know your patients helps to promote dignified care.

The Dignity in Care Project aims to develop practical interventions to promote dignified care in hospitals, embedded in the project slogan: "Everybody matters: sustaining dignity in care." It is a nurse led research collaboration with Royal Free Hampstead and Barnet and Chase Farm Hospitals Trusts and City University. Practical interventions devised by the project are presented around three main themes that emerged from the views of older people and their relatives (Bridges et al, 2010; 2009). The first theme of "maintaining identity--see who I am" focuses on knowing about people, while the second of "creating community--connect with me" recognises that in the act of caring, nurses receive as well as give. The last theme of "shared decision making--involve me" looks at how decisions about care are made. This first article in a three part series summarises the project and focuses on the first theme. It reports on practical initiatives to enhance dignity in hospitals by enabling nurses and patients/carers to know and value each other as people.

Optimising EEG-fMRI for Localisation of Focal Epilepsy in Children.

BACKGROUND: Early surgical intervention in children with drug resistant epilepsy has benefits but requires using tolerable and minimally invasive tests. EEG-fMRI studies have demonstrated good sensitivity for the localization of epileptic focus but a poor yield although the reasons for this have not been systematically addressed. While adults EEG-fMRI studies are performed in the "resting state"; children are commonly sedated however, this has associated risks and potential confounds. In this study, we assessed the impact of the following factors on the tolerability and results of EEG-fMRI in children: viewing a movie inside the scanner; movement; occurrence of interictal epileptiform discharges (IED); scan duration and design efficiency. This work's motivation is to optimize EEG-fMRI parameters to make this test widely available to paediatric population. METHODS: Forty-six children with focal epilepsy and 20 controls (6-18) underwent EEG-fMRI. For two 10 minutes sessions subjects were told to lie still with eyes closed, as it is classically performed in adult studies ("rest sessions"), for another two sessions, subjects watched a child friendly stimulation i.e. movie ("movie sessions"). IED were mapped with EEG-fMRI for each session and across sessions. The resulting maps were classified as concordant/discordant with the presumed epileptogenic focus for each subject. FINDINGS: Movement increased with scan duration, but the movie reduced movement by ~40% when played within the first 20 minutes. There was no effect of movie on the occurrence of IED, nor in the concordance of the test. Ability of EEG-fMRI to map the epileptogenic region was similar for the 20 and 40 minute scan durations. Design efficiency was predictive of concordance. CONCLUSIONS: A child friendly natural stimulus improves the tolerability of EEG-fMRI and reduces in-scanner movement without having an effect on IED occurrence and quality of EEG-fMRI maps. This allowed us to scan children as young as 6 and obtain localising information without sedation. Our data suggest that ~20 minutes is the optimal length of scanning for EEG-fMRI studies in children with frequent IED. The efficiency of the fMRI design derived from spontaneous IED generation is an important factor for producing concordant results.