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It appears to gastritis pain remedy lansoprazole 30 mg amex be widely distributed in the body gastritis zinc lansoprazole 15mg lowest price, with higher concentrations in adipose tissue and brain gastritis diet žÚŮ lansoprazole 30 mg with visa. In rats gastritis gurgling purchase lansoprazole without a prescription, brain mephobarbital levels were eight times those simultaneously measured in blood (52). In vitro studies suggest that 58% to 68% of mephobarbital in highly concentrated solution is bound to human serum albumin (53). Mephobarbital is metabolized to phenobarbital by demethylation in the liver (54,55) and is affected by the cytochrome P450 system (56). A portion is excreted in human urine as a p-hydroxyphenyl glucuronide derivative of the parent drug (57). Phenobarbital is a known liver enzyme inducer, with this effect possibly responsible for the decrease in mephobarbital elimination half-life from approximately 50 hours initially to 12 to 24 hours during long-term therapy. Because of the slower metabolism of phenobarbital, its steady-state plasma concentrations exceed those of the parent drug. Probably for that reason, the therapeutic range of mephobarbital traditionally has been expressed in terms of plasma phenobarbital concentrations. Some believe that by ignoring plasma mephobarbital levels, a measure of one active anticonvulsant substance present in the body may be overlooked (59). It is argued that because of its apparent high volume of distribution relative to that of phenobarbital and its lipid solubility, mephobarbital probably has substantially higher brain levels than plasma levels compared with phenobarbital. Steady-state plasma phenobarbital levels correlate closely with mephobarbital dose. Mephobarbital dosages of 3 to 4 mg/kg/day produce mean plasma phenobarbital levels of 15 g/mL; a dosage of 5 mg/ kg/day produces mean levels of 20 g/mL (59). At higher mephobarbital doses and plasma levels, proportionately lower phenobarbital plasma levels are seen. This may suggest a ratelimited metabolism at high plasma mephobarbital concentrations (59). In one small study (60), plasma phenobarbital levels averaged 20 times those of mephobarbital (conversion for mephobarbital: [mol/L] 4. Interactions with Other Agents and Adverse Effects Any interaction that is known to occur with phenobarbital (see Chapter 53) probably will also happen with mephobarbital. Subtle adverse effects in the form of intellectual impairment and depression of cognitive abilities are of major concern in patients receiving long-term therapy with mephobarbital or metharbital (61). Other untoward reactions include hypnotic effects, irritability, hyperactivity, and alterations in sleep patterns. Up to 40% of children and probably as many elderly patients taking phenobarbital experience unpleasant side effects (11). Impairment of immediate memory and attention has been demonstrated with long-term phenobarbital use at therapeutic plasma drug levels (62,63). This effect on short-term memory and attention is a significant problem, considering the large number of school-aged children who receive phenobarbital or mephobarbital. In one study (64), six of 11 children on maintenance doses of phenobarbital or mephobarbital had clear behavioral changes, including irritability, oppositional attitudes, and overactivity, compared with age-matched controls. Many of our patients reported feeling "dumb" or "mentally dull" when they received barbiturate drugs. In others, already taking barbiturates when referred to us, intellectual impairment became apparent in retrospect after the drug was withdrawn. Another side effect of phenobarbital that is unintentionally ignored by physicians is impotence or decreased libido. Usually, male patients are reluctant to discuss their sex lives, and physicians tend to ascribe the problem to psychosocial conflict. Nevertheless, mephobarbital is reputed to be as effective as phenobarbital in humans and less sedative (59). National Health Service prescriptions for mephobarbital in Australia have remained similar to those for phenobarbital and primidone over several years (59). There is no reason to believe that mephobarbital is more effective or has a wider anticonvulsant spectrum than the less expensive phenobarbital. It is difficult to differentiate the anticonvulsant effect of the parent drug, mephobarbital, and that of its active metabolite, phenobarbital, during long-term treatment in humans. Of 56 patients who took phenobarbital for 1 year, 14% reported a transient or continuous decrease in sexual function. The problem usually disappeared when phenytoin or carbamazepine was substituted for phenobarbital, but not when phenobarbital was changed to another barbiturate. High doses of acetazolamide may produce a paradoxical effect, resulting in disruption of acid¬≠base homeostasis in the brain (77). Woodbury (78) showed that the development of tolerance to acetazolamide is attributable to the induction of increased carbonic anhydrase synthesis in glial cells and to glial proliferation. Because acetazolamide is a weak acid, most of its absorption takes place in the duodenum and upper jejunum after some amount has been absorbed in the stomach. After distribution to various tissues, it binds to carbonic anhydrase and remains in a relatively stable carbonic anhydrase¬≠acetazolamide complex. It is eliminated in the urine unchanged through glomerular filtration, tubular filtration, and tubular secretion. Acetazolamide is also excreted in the bile to be resorbed from the intestinal tract. Inhibition of carbonic anhydrase activity was observed when sulfanilamide was introduced as a chemotherapeutic agent. A large number of sulfonamides have been synthesized and tested as carbonic anhydrase inhibitors and potential diuretics. Transient or intermittent use of acetazolamide is beneficial when seizures are temporarily exacerbated. The drug can be started 5 days before the expected onset of menses and continued for 11 to 14 days. With a half-life of 2 to 4 days, steady-state plasma levels occur 5 to 7 days after the initial dose, and adequate levels continue for 3 to 5 days after the agent is discontinued. In a retrospective study of 20 women with catamenial epilepsy, 40% reported a 50% or greater decrease in seizure frequency; the response rates were similar in generalized versus focal epilepsy and temporal versus extratemporal epilepsy (80). In a retrospective study of 31 patients with juvenile myoclonic epilepsy treated with long-term acetazolamide monotherapy, generalized tonic¬≠clonic seizures were controlled in 45% (81). None of the patients (n 28) that were examined after longterm acetazolamide therapy, which ranged from 10 months to Chemistry and Mechanism of Action Acetazolamide (Diamox,4 N-(5-sulfamoyl-1,3,4-thiadiazol-2yl-)acetamide;. In the brain, acetazolamide acts through inhibition of carbonic anhydrase, causing carbon dioxide to accumulate and inducing the anticonvulsant action. Blocking carbonic anhydrase in other tissues, particularly red blood cells, causes even greater retention of carbon dioxide in the brain (71). This results in blockade of anion transport, which prevents spread of seizure activity and elevates seizure threshold. The anticonvulsant effect of acetazolamide, as measured by prevention of maximal electroshock-induced seizures (72,73), correlates with the degree of inhibition of brain carbonic anhydrase. The carbonic anhydrase inhibitory effect with subsequent increase in intracellular carbon dioxide is probably responsible for the anticonvulsant properties of acetazolamide (75). Chapter 68: Less Commonly Used Antiepileptic Drugs 785 14 years, showed evidence of renal calculi. A summary of the pharmacologic and pharmacokinetic properties, efficacy, and safety of acetazolamide in the treatment of epilepsy has been published (83). The recommended daily dosage is 10 mg/kg given in a single dose or in two or three divided doses. Usual effective therapeutic plasma levels range from 8 to 14 g/mL (conversion for acetazolamide: mol/L 4. Another recent hypothesis is that there may be an abnormality of pyridoxine transport, which underlies the pathophysiology of the disorder (98). Interactions with Other Agents and Adverse Effects Elimination of acetazolamide may decrease and the half-life of the agent may increase with the concomitant use of probenecid, which blocks renal tubular secretion of acids. The absorption of salicylate may be increased and that of amphetamine may be delayed when these drugs are taken with acetazolamide. Acetazolamide is a relatively benign agent, with only a few adverse effects known.

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If a lesion is found gastritis diet questions purchase online lansoprazole, it may not necessarily reflect the epileptogenic zone and additional information is needed to gastritis diet foods generic lansoprazole 15mg with amex support the hypothetical epileptogenic zone diet for gastritis patients effective 15 mg lansoprazole. However gastritis diet therapy purchase 15 mg lansoprazole visa, history and other investigations may suggest that only one tuber is the epileptic lesion. To detect subtle abnormalities, curvilinear reformatting of 2D images is used to reconstruct the images into thin, curved slices where the distance from the surface of the hemispheric convexities is kept constant (100). An interictal image is subtracted from the ictal image to derive the difference in cerebral blood flow related to focal seizures (110). The goal of epilepsy surgery is to remove the epileptogenic zone, while preventing functional deficits. Neuropsychological testing is used to provide additional quantification and localizing information of cognitive deficits that hint at the functional deficit zone. Neuropsychological findings can also anticipate possible cognitive decline after epilepsy surgery. This is especially important if the epileptogenic zone or lesion is in close proximity or overlapping with eloquent areas. Besides defining eloquent cortex, it can be used to lateralize and localize the epileptogenic zone by showing regions of functional deficit. The Wada test involves angiography and injection of a short-acting barbiturate into the internal carotid artery in order to temporarily simulate the effects of epilepsy surgery on language and memory. It is used to lateralize eloquent areas and functional deficit zone, in particular language and memory function (112­115). Blood flow increase exceeds the increase in local cerebral oxygen, and this leads to a localized increase in the ratio of oxyhemoglobin to deoxyhemoglobin (27,28). It can localize brain function and functional deficits, and may therefore serve as an estimate of the functional deficit zone. Decreased metabolism reflects decrease in glucose influx from reduced glucose transport across the blood­brain barrier and reduced phosphorylation (102). Decreased metabolism is thought to represent the functional deficit zone and may be related to various factors, such as underlying structural lesion, inhibitory mechanisms of seizures, atrophy, neuronal loss, decreased synaptic activity, and postictal depression of metabolism. This method can detect interictal spike-related changes and may be helpful in the localization of interictal epileptiform discharges. Main goal is development of a localization hypothesis on the basis of available information. The ultimate goal of preoperative planning is to provide patients with seizure reduction or freedom, improved quality of life, and minimal deficit. This can be achieved by an understanding and demarcation of the epileptogenic zone, which is unique to each epilepsy patient, and when completely resected renders the patient seizure-free. John Hughlings Jackson and the cortical motor centres in the light of physiological research. Magnetoencephalography: evidence of magnetic fields produced by alpha-rhythm currents. Interhemispheric differences in the localization of psychological processes in man. Localized analyses of the function of the human brain by the electro-encephalogram. Oxygenation dependence of the transverse relaxation time of water protons in whole blood at high field. Dominant temporal lobe resections can lead to difficulties in learning or retaining verbal information (126­128). Deficit in nonverbal tasks after resection of the nondominant temporal lobe have also been described (129­131). Effective epilepsy surgery can lead to a significant reduction of seizures or seizure freedom, leading to better quality of life, less injuries secondary to seizures, and possibly improvements in development and cognition. Successful surgery can only be performed after a detailed evaluation to define the epileptogenic zone pre- and perioperatively. The process begins with a localization hypothesis using clinical history of ictal semiology to delineate the symptomatogenic zone and possibly the functional deficit zone. Once medical intractability is confirmed, this hypothesis is corroborated by other diagnostic modalities. These confirm localization and prevent deficits, and add further information on ictal-onset zone and irritative zone as well as eloquent areas. Choice of studies depends on cost, availability, and experience at different institutions. Early surgical intervention is important, as hesitancy may lead to death as well as decreased development in the pediatric population (132,133). Brain plasticity in children secondary to neurogenesis and synapse formation may allow transfer of function and may lead to fewer deficits in patients undergoing with earlier surgery (134,135). New technologies will provide additional tools for the successful identification of this hypothetical region in the future. Dystonic posturing in complex partial seizures of temporal lobe onset: a new lateralizing sign. Lateralizing value and semiology of ictal limb posturing and version in temporal lobe and extratemporal epilepsy. The lateralizing value of ictal clinical symptoms in uniregional temporal lobe epilepsy. The lateralizing significance of versive head and eye movements during epileptic seizures. Pattern-induced partial seizures with repetitive affectionate kissing: an unusual manifestation of right temporal lobe epilepsy. Automatisms with preserved responsiveness: a lateralizing sign in psychomotor seizures. Ictal urinary urge: further evidence for lateralization to the nondominant hemisphere. Ictal vomiting in association with left temporal lobe seizures in a left hemisphere language-dominant patient. Postictal nose wiping: a lateralizing sign in temporal lobe complex partial seizures. In vivo laminar electrophysiology co-registered with histology in the hippocampus of patients with temporal lobe epilepsy. Electroencephalogram-triggered functional magnetic resonance imaging in focal epilepsy. Incomplete resection of focal cortical dysplasia is the main predictor of poor postsurgical outcome. Imaging epileptogenic tubers in children with tuberous sclerosis complex using alpha-11(C)methyl-Ltryptophan positron emission tomography. Multimodality imaging for improved detection of epileptogenic lesions in children with tuberous sclerosis complex. Functional neuroimaging in the preoperative evaluation of children with drug-resistant epilepsy. Epileptic activity influences the speech organization in medial temporal lobe epilepsy. Automatisms with preserved responsiveness and ictal aphasia: contradictory lateralising signs during a dominant temporal lobe seizure. Long-term follow-up after temporal lobe resection for lesions associated with chronic seizures. Occipital lobe epilepsy: electroclinical manifestations, electrocorticography, cortical stimulation and outcome in 42 patients treated between 1930 and 1991. Approach to pediatric epilepsy surgery: state of the art, Part I: general principles and presurgical workup. Sturge­Weber syndrome: a study of cerebral glucose utilization with positron emission tomography. Identification of frontal lobe epileptic foci in children using positron emission tomography. Pre-surgical evaluation and surgical outcome of 41 patients with non-lesional neocortical epilepsy.

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The program can also serve children 18 years of age and under at domestic violence and homeless shelters gastritis diet „ÓūÓŮÍÓÔ best order for lansoprazole. Age of Patient Children 18 and under How It Works Free gastritis recipes order lansoprazole online, healthy snacks and/or meals meeting federal nutrition standards in enrichment programs running afterschool gastritis constipation lansoprazole 15mg overnight delivery, on weekends gastritis diet ÔŚūŚ‚ÓšųŤÍ cost of lansoprazole, or during school holidays Who Can Apply Children can access free meals at participating enrichment programs offered at community sites, including schools, park and recreation centers, libraries, faith-based organizations, or community centers Afterschool Nutrition Programs the Afterschool Nutrition Programs provide federal funding to school-based, agency-based, and community-based programs operating in low-income areas after school, on weekends, and during school holidays to serve meals and snacks to youth 18 years of age and under. The free nutritious snacks and meals help draw children and adolescents to programs that provide a safe place for them to be engaged and to learn. Age of Patient Children 18 and under How It Works Up to two free meals at approved school and community sites during summer vacation Meals must meet approved federal nutrition standards Who Can Apply Children can access meals at participating community sites, which can include schools, park and recreation centers, libraries, faith-based organizations, or community centers No need to show identification Summer Nutrition Programs the Summer Nutrition Programs provide meals to children 18 years of age and under at school-based, public agency-based, and nonprofit sites that offer educational, enrichment, physical, and recreational activities during the weeks between the end and start of the school year. This ensures that children who receive school meals during the school year receive continued good nutrition over the summer. Research shows that children are more vulnerable to food insecurity during the summer break. Summer meal sites american academy of pediatrics and the food research & action center february 2017 20 must be located in a low-income area or serve a majority of children who qualify for free or reduced-price school meals. This means that once allocated funds are depleted, the program cannot serve more participants. The program aims to increase the variety of fruits and vegetables children consume, and to create healthier school food environments. Limited federal funding is available to schools in all 50 states and the District of Columbia. States provide the food and administrative funds to local organizations, often food banks, which then distribute the food to local pantries, food shelves, and soup kitchens that directly work with low-income populations. The amount of food and funds received by a state varies based on its lowincome and unemployed populations. For program eligibility at a glance, review the Federal Nutrition Program and Emergency Food Referral Chart. Pediatric medical teams can intervene on four fronts: Administer appropriate medical interventions for the patient per your protocols. Connect patients and their families to the federal nutrition programs and other food resources. Support advocacy and education efforts to end childhood food insecurity, and that promote the nutrition, well-being, and economic security of low-income families. Connecting patients to emergency food sources, such as food banks and food pantries (also known as food shelves), is also a viable option, especially for addressing immediate needs. However, emergency food sites may not be available in your area, have limited hours of operation and food options, or have limits on the amount of food they provide. Even when emergency food sites are available, a family may not have transportation to get to a site or meet the criteria for getting free food from the site. Become familiar with the Federal Nutrition Program and Emergency Food Referral Chart. It provides an overview of the key federal nutrition programs, and it allows you to customize referral information to your local area. Additionally, contact your local food bank to learn more about emergency food and other resources. In addition to anti-hunger organizations, other groups are available to help you get started. Consider contacting your local food bank, community action agency, or social service organizations. Patients are more likely to connect with nutrition resources if they receive immediate assistance. However, not every practice will be able to devote sufficient internal staff time to individually screen and connect all patients on site to the range of available nutrition and emergency food programs, especially those additional interventions identified in Step 4 (see page 32). As such, there are different ways the wide range of pediatric practices - from big to small, from urban to rural - are intervening to address food insecurity. General guidance is provided below for developing internal capacity and community partnerships. Developing Internal Capacity To create a sustainable intervention model, it is important to identify internal staff or volunteers that can work with families to access nutrition and other benefits. The following individuals may be able to assist with this work: social workers, case managers, receptionists, patient navigators, community health workers, financial assistance counselors, medical residents, student interns, in-house lawyer/paralegal with Medical-Legal Partnerships, Health Leads desks, or AmeriCorps volunteers. Many of these responsibilities do not require much staffing time and can be easily integrated into existing job responsibilities, while others may need a full-time or parttime position, depending on the size of your practice. Determine what is most important for your patients/families and most feasible for your practice. Local public health, nonprofit, and faith-based organizations may also be key partners. The medical team identifies a local organization that can help patients and families access federal nutrition programs, locate emergency food, or identify other nutrition interventions. In some instances, community partners may support additional interventions (see page 32) when the health care site does not have sufficient internal capacity to staff these efforts. If so, can the community organization apply for funding or will funding be pursued jointly? If the community organization has funding to use toward the partnership, what does it need to fulfill the grant requirement? If you are a nonprofit hospital, does the community health needs assessment include nutrition or anti-hunger activities where community benefit dollars may be available? Tracking: Can information on patient referrals or use of federal nutrition programs or food resources be collected? Posting federal nutrition program messaging in public areas of your practice is one way of destigmatizing the use of federal nutrition programs. The messaging also can reinforce how the programs benefit nutrition, health, and well-being. These materials contain national numbers for accessing federal nutrition programs, but local referral information can be added, too. Connecting families to federal nutrition and existing emergency food programs is the critical first step to address food insecurity. Tips: When deciding whether you can pursue any of these additional interventions, ask your practice team: Is the practice maximizing opportunities to ensure that eligible patients and families are connected to the federal nutrition programs? In addition to connecting patients to these programs, some providers across the country are exploring additional interventions aimed at providing on-site. This chart briefly describes the most common interventions to support patients struggling with food insecurity. Health providers can either help families access these programs directly or refer families to community partners. For more information on how to connect patients to these programs, visit. Criteria for which patients get free food items and how often varies Grocery Bags: Through a partnership with a local food bank, health providers distribute bags of groceries to patients periodically, typically once a month. The medical team and/or the food bank partner determine criteria for which patients get free food items Gift Cards to Local Supermarket: Practitioners distribute gift cards to a local supermarket to families in need of immediate food assistance. This allows patients 18 years of age and under ready access to up to two free meals in a safe and convenient setting. Meals must meet nutrition standards, be served in a group setting, and cannot be taken home. Sites get reimbursed for meals served as well as some of the administrative costs of the program Afterschool Meal Site: Through available federal funding, health care providers are offering out-of-school time meals after school, on weekends, or during school holidays to children 18 years of age and under. The patient then selects indicated foods from the food pharmacy and receives referrals to return once a month for six months. The structure of the program and the value of the "prescription" patients receive varies depending on the model. Advocacy Actions Pediatricians can advocate for greater food security, better nutrition, and the improved overall health of children and their families by: Ten Advocacy Actions Pediatricians Can Take to Address Childhood Food Insecurity 1) Write an Op-Ed or Letter to the Editor. Download the full Ten Advocacy Actions Pediatricians Can Take to Address Childhood Food Insecurity. It should also lift the cap on the shelter deduction so the program can take into consideration the needs of families with high housing costs.

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Neighborhood Characteristics Associated With Access To Patient-Centered Medical Homes For Children gastritis and gas buy discount lansoprazole on-line. Social class gastritis diet of hope buy lansoprazole 15 mg online, parental education and obesity prevalence in a study of six-year-old children in Germany gastritis symptoms pregnancy purchase cheap lansoprazole online. Family poverty and neighborhood poverty: Links with childrens school readiness before and after the Great Recession gastritis diet 5 days buy lansoprazole amex. Cumulative Hardship and Wellness of Low-Income, Young Children: Multisite Surveillance Study. Advancing State Innovation Model Goals through Accountable Communities for Health Center for Health Care Strategies Issue brief. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. Addressing the Social Determinants of Health Through Medicaid Managed Care the Commonwealth Fund Issue brief. Self-administered Questionnaire for Structured Psychosocial Screening in Pediatrics. Can a Video Curriculum on the Social Determinants of Health Affect Residents Practice and Families Perceptions of Care? Avoiding the Unintended Consequences of Screening for Social Determinants of Health. Caregiver Opinion of In-Hospital Screening for Unmet Social Needs by Pediatric Residents. Brief report: learning to parent: a survey of parents in an urban pediatric primary care clinic. Training in Social Determinants of Health in Primary Care: Does it Change Resident Behavior? Youths Health-Related Social Problems: Concerns Often Overlooked During the Medical Visit. Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care? Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management. Effects of Social Needs Screening and In-Person Service Navigation on Child Health. Multiple Behavior Change Intervention to Improve Detection of Unmet Social Needs and Resulting Resource Referrals. Connecting At-Risk Inpatient Asthmatics to a Community-Based Program to Reduce Home Environmental Risks: Care System Redesign Using Quality Improvement Methods. Training Pediatric Residents in a Primary Care Clinic to Help Address Psychosocial Problems and Prevent Child Maltreatment. Assessing and referring adolescents health-related social problems: qualitative evaluation of a novel web-based approach. Assessing and Managing the Social Determinants of Health: Defining an Entrustable Professional Activity to Assess Residents Ability to Meet Societal Needs. Teaching social determinants of child health in a pediatric advocacy rotation: Small intervention, big impact. The Childrens Advocacy Project of Philadelphias Cap4Kids Survey: An Innovative Tool for Pediatrician-Community-Based Organization Collaboration. Surveillance and Screening for Social Determinants of Health-Where Do We Start and Where Are We Headed? Medical-Legal Partnerships: Transforming Primary Care By Addressing the Legal Needs Of Vulnerable Populations. Pilot Study of Medical-Legal Partnership to Address Social and Legal Needs of Patients. Addressing basic resource needs to improve primary care quality: a community collaboration programme. Linking urban families to community resources in the context of pediatric primary care. Prevalence of Developmental Delays and Participation in Early Intervention Services for Young Children. The Inherent Fallibility of Validated Screening Tools for Social Determinants of Health. From Medical Home to Health Neighborhood: Transforming the Medical Home into a CommunityBased Health Neighborhood. A Road Map to Address the Social Determinants of Health Through Community Collaboration. Using Social Determinants of Health Data to Improve Health Care and Health: A Learning Report. Addressing the Social Determinants of Health Within the Patient-Centered Medical Home. Equivalence of Electronic and Paperand-Pencil Administration of Patient-Reported Outcome Measures: A MetaAnalytic Review. A Randomized Trial on Screening for Social Determinants of Health: the iScreen Study. Development of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health. The Safe Environment for Every Kid Model: Impact on Pediatric Primary Care Professionals. Screening for intimate partner violence in an urban pediatric primary care clinic. Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Improving Social Determinants of Health: Effectiveness of a Web-Based Intervention. Referral System Collaboration Between Public Health and Medical Systems: A Population Health Case Report. Clinical Interventions Addressing nonmedical Health Determinants in Medicaid Managed Care. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U. Opinions or points of view expressed are those of the authors and do not necessarily reflect the official position or positions of the U. Leaders who promote values that advance safety, dignity, and respect for all residents, inmates, and staff; 2. Officials who actively seek better ways to manage the population and who integrate knowledge and ideas from a wide variety of sources including staff, professional associations, accreditation processes, and other agencies and facilities; 3. Open communication between managers and correctional staff, and between correctional staff and inmates and residents; 4. Recruitment and hiring of diverse individuals who are respectful towards others and have effective communication skills, and mentoring and succession planning; 5. Standardized and ongoing staff training to transmit values through policies and practices; 6. Direct supervision architecture and direct supervision principles for the behavior management of residents and inmates; 7. Programs and services to (a) productively occupy the time of inmates, (b) meet the needs of prisoners and juveniles, and (c) improve the life outcomes of those who are incarcerated; 8. An objective classification system used to facilitate safety for inmates and staff; 9. A comprehensive and independent investigation process that emphasizes the following: training security investigation and medical staff in responding appropriately to victims, effective investigation techniques, and promotes crosstraining responding immediately to all reports of sexual assault investigating all incidents of sexual assault sensitively responding to victims prosecuting criminal behavioral when appropriate 10. A system of data collection, analysis, and incident tracking system that enables effective, datadriven decision making; and 11. Brief summary of leadership approaches i 26 29 35 38 45 50 53 58 63 67 75 183 209 261 287 289 301 313 329 341 12 13 20 32 44 46 51 54 60 63 Table 4. Description of sexual assault investigation procedures in five facilities Table 9.

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