Access to legacy-oriented interventions at end of life for pediatric oncology patients: A decedent cohort review

BACKGROUND

Legacy-oriented interventions have the potential to offer pediatric oncology patients and families comfort at end of life and during bereavement. Certified child life specialists often provide these services, and presently little is known about whether disparities exist in the provision of legacy-oriented interventions.

METHODS

In this retrospective decedent cohort study, we examined demographic and clinical characteristics from a sample of 678 pediatric oncology patients who died between 2015 and 2019. Bivariate analysis assessed differences between patients who received any versus no legacy-oriented intervention. Uni- and multivariable logistic regression models assessed associations of baseline characteristics and likelihood of receiving legacy-oriented intervention. Further multivariable analysis explored joint effects of significant variables identified in the univariable analysis.

RESULTS

Fifty-two percent of patients received a legacy-oriented intervention. Older adolescents (≥13 years) were less likely (odds ratio [OR]: 1.73, p = .007) to receive legacy-oriented interventions than younger ones. Patients with home/hospice deaths were also less likely (OR: 19.98, p < .001) to receive interventions compared to patients who passed away at SJCRH locations. Hispanic patients (OR: 1.53, p = .038) and those in palliative care (OR: 10.51, p < .001) were more likely to receive interventions. No significant race association was noted.

CONCLUSION

All children and adolescents with cancer deserve quality care at end of life, including access to legacy-oriented interventions, yet nearly half of patients in this cohort did not receive these services. By identifying demographic and clinical characteristics associated with decreased odds of receiving legacy-oriented interventions, healthcare professionals can modify end-of-life care processes to improve access. Introducing legacy-oriented interventions early and increasing exposure in community spaces may enhance access to legacy-oriented interventions for pediatric oncology patients.

Legacy in paediatrics: A concept analysis

AIM

To provide an analysis of legacy and legacy-oriented interventions in paediatric healthcare.

DESIGN

Walker and Avant's method of concept analysis.

METHODS

Using Walker and Avant's method, three defining attributes of the concept were determined, followed by antecedents, consequences, and empirical referents of legacy.

RESULTS

In paediatrics, legacy is co-authored in relationships, has the capability to outlive the person or event it represents, and elicits the essence of a person or experience. Receiving legacy-oriented interventions are not a prerequisite for having a legacy, nor is death.

CONCLUSION

Engaging in purposeful, individualized legacy-oriented interventions can improve coping in paediatric patients, families, and providers. By understanding the concept of legacy, providers are better equipped to provide care honouring the unique personhood, relationships, and strengths of children and families in even the most dire circumstances.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the scope and purpose of legacy in paediatrics assists providers in improving patient- and family-centred outcomes by designing interventions that facilitate long-term coping in patients facing a loss of or significant change in health, normalcy, or life.

IMPACT

Legacy-oriented interventions are provided at most children's hospitals in the United States, yet no widespread consensus on foundation or scope has been determined. This concept analysis provides evidence-based guidelines for policy and practice in creating legacy for and with children, providing opportunities to improve quality of care for young patients and their families around the world.

REPORTING METHOD

N/A.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Cajal, the neuronal theory and the idea of brain plasticity

This paper reviews the importance of Cajal's neuronal theory (the Neuron Doctrine) and the origin and importance of the idea of brain plasticity that emerges from this theory. We first comment on the main Cajal's discoveries that gave rise and confirmed his Neuron Doctrine: the improvement of staining techniques, his approach to morphological laws, the concepts of dynamic polarisation, neurogenesis and neurotrophic theory, his first discoveries of the nerve cell as an independent cell, his research on degeneration and regeneration and his fight against reticularism. Second, we review Cajal's ideas on brain plasticity and the years in which they were published, to finally focus on the debate on the origin of the term plasticity and its conceptual meaning, and the originality of Cajal's proposal compared to those of other authors of the time.

Bailey: The Life and Legacy of an Educator, Humanitarian, and Leader

Dr Byron J. Bailey, a preeminent figure in the field of Otolaryngology, exemplified an unwavering commitment to patient care, resident education, research excellence, and humanitarian endeavors throughout his illustrious career. Born in 1934, Dr Bailey played a pivotal role in the growth and success of the Department of Otolaryngology at the University of Texas Medical Branch. A dedicated educator and researcher, he authored groundbreaking research and the seminal textbook, Bailey's Head and Neck Surgery-Otolaryngology. His leadership in major organizations and commitment to research integrity and quality are hallmarks of his career. Dr Bailey's philanthropic pursuits include improving Otolaryngology care and access in Vietnam and Cuba, and local community efforts in Galveston, Texas. His enduring legacy continues to inspire future generations of Otolaryngologists, serving as a testament to the power of perseverance and dedication to excellence in the pursuit of medical education.

200 years of pasteurizing the world of science

Professor Henrik C. Wegener, Rector of the University of Copenhagen, writes about the impact of Louis Pasteur and his legacy as a role model in science at the centennial of the Danish Pasteur Society and the bicentennial of Pasteur's birth.

Persistence of Root Exudates of Sorghum bicolor and Solidago canadensis: Impacts on Invasive and Native Species

Root exudates of the invasive Solidago canadensis and the cereal crop Sorghum bicolor (L.) Moench cv. 'Hybridsorgo' were tested for allelopathic interactions against native and invasive plant species in a controlled environment. After the surface was sterilized, the seeds of two invasive species (Bromus sterilis and Veronica persica) and two native species (Youngia japonica and Rumex acetosa) were germinated and transplanted into the soil (1:1 mixture of coco peat and sand) that had been conditioned for one month by the cultivation of Solidago canadensis and Sorghum bicolor, both in combination or as unplanted controls. After an additional eight weeks of growth, morphometric measurements of the shoot and root, including foliar characteristics and above- and below-ground biomass accumulation, were performed. The results revealed significant inhibitory effects of root exudates released by Sorghum bicolor and Solidago canadensis on native species' productivity and physiology. The invasive species exhibited variable growth responses, with Veronica persica showing reduced shoot and root expansion, but Bromus sterilis revealed increased shoot and root biomass allocation and nutrition under the exudate treatments. Exudates from Solidago canadensis and Sorghum bicolor together showed synergistic negative effects on native species, while they promoted growth and nutrition in Veronica persica. Taken together, the differential species responses indicate that the tested native species were more sensitive to the allelopathic compounds than the invasive species, which is in line with the theory of novel weapons. The legacy effects of root exudates of both Sorghum bicolor and Solidago canadensis could promote invasive establishment through imposing allelochemical interference competition against native plant species. Understanding the specific allelopathic mechanisms may help with the development of integrated strategies for managing invasive species.

The long-term benefits of early intensive therapy in chronic diseases-the legacy effect

The 'legacy effect' refers to the long-term benefits of intensive therapy that are observed long after the end of clinical trials and trial interventions in chronic diseases such as diabetes, hyperlipidaemia and hypertension. It emphasizes the importance of intensive treatment to prevent long-term complications and mortality. In chronic kidney disease (CKD), the legacy effect is evident in various studies. Long-term nephroprotection in diabetes is well documented in major studies in the early stages of diabetes, such as Diabetes Control and Complications Trial-Epidemiology of Diabetes Interventions and Complications (DCCT-EDIC), UK Prospective Diabetes Study (UKPDS) and Intensified Multifactorial Intervention in Patients with Type 2 Diabetes and Microalbuminuria (STENO-2). These studies highlight the importance of intensive glycaemic control in reducing microvascular complications, including nephropathy, in patients with recently diagnosed type 1 and type 2 diabetes. However, the legacy effect is less evident in patients with long-term, established diabetes. In chronic glomerulonephritis, studies on immunoglobulin A nephropathy showed that early immunosuppressive treatment could have long-term beneficial effects on kidney function in children and adults with CKD. The Frequent Hemodialysis (FH) and the EXerCise Introduction To Enhance Performance in Dialysis (EXCITE) trials indicated that frequent haemodialysis and a personalized walking exercise program could improve clinical outcomes and reduce the long-term risk of death and hospitalization. The legacy effect concept underscores the importance of intensive intervention in chronic diseases, including CKD. This concept has significant implications for public health and warrants in-depth basic and clinical research to be better understood and exploited in clinical practice. However, its limitations should be considered when interpreting long-term observational data collected after a clinical trial. Appropriate study designs are necessary to investigate an unbiased legacy effect.

Progress with the regulation of radiation safety during recovery and removal of spent nuclear fuel from the site for temporary storage at Andreeva Bay on the Kola Peninsula

In the 1960s, a shore technical base (STB) was established at Andreeva Bay on the Kola Peninsula, in northwest Russia. The STB maintained nuclear submarines and the nuclear icebreaker fleet, receiving and storing fresh and spent nuclear fuel (SNF) as well as solid and liquid radioactive waste (RW). It was subsequently re-designated as a site for temporary storage (STS) for SNF and RW. Over time, the SNF storage facilities partly lost their containment functions, leading to radioactive contamination of workshops and the site above permitted values. The technological and engineering infrastructure at the site was also significantly degraded as well as the condition of the stored SNF. At present, the STS Andreeva Bay facility is under decommissioning. This paper describes progress with the creation of safe working measures for workers involved in site remediation and SNF recovery operations, including the determination of safe shift times in high radiation areas, as part of overall optimization of safety. Results are presented for the successful application of these measures in the period 2019-2021, during which time significant SNF recovery and removal operations were completed without incident. Significant important experience has been gained to support safe removal of remaining SNF, including the most hazardous degraded fuel, as well as recovery of other higher level RW and decommissioning of the old storage buildings and structures.

"I need my granddaughter to know who I am!" A case study of a 67-year-old African American man and his spiritual legacy

This case study describes the spiritual care relationship between an African American man receiving palliative care for metastatic cancer and a Chinese American woman chaplain over the period of multiple hospitalizations. It illustrates legacy making as a key spiritual need, one that is complicated by discrimination, structural racism, estranged family relationships, and the patient's own mortality. Included are verbatim conversations that address the impact of racism in the US context and express the complex identities of both patient and chaplain in a dynamic and collaborative intercultural relationship. This case posits the importance of voices of chaplains of color and encourages all chaplains to develop caregiving capacities that address patients' needs for racial justice, meaning, and spiritual legacy.

Pond Sediments Reveal the Increasing Importance of Road Runoff as a Source of Metal Contamination in Industrialized Urban Environments Downwind of Pittsburgh, Pennsylvania (USA)

Toxic levels of trace metals from human activities accumulate in natural environments, yet these metal mixtures are rarely characterized or quantified. Metal mixtures accumulate in historically industrial urban areas and change as economies shift. Previous research has often focused on the sources and fate of a specific element, which limits our understanding of metal contaminant interactions in our environment. Here, we reconstruct the history of metal contamination in a small pond downstream of an interstate highway and downwind of fossil fuel and metallurgical industries that have been active since the middle of the nineteenth century. Metal contamination histories were reconstructed from the sediment record using metal ratio mixing analysis to attribute the relative contributions of contamination sources. Cadmium, copper, and zinc concentrations in sediments accumulated since the construction of major road arteries in the 1930s and 40s are, respectively, 3.9, 2.4, and 6.6 times more concentrated than those during industry-dominated time periods. Shifts in elemental ratios suggest these changes in metal concentrations coincide with increased contributions from road and parking lot traffic, and to a lesser extent, from airborne sources. The metal mixture analysis demonstrates that in near-road environments, contributions from modern surface water pathways can obscure historical atmospheric industrial inputs.

Ernesto Bustamante Zuleta (1922-2021): pioneering teacher and practitioner of Colombian neurosurgery

Ernesto Bustamante Zuleta (1922-2021) was an impactful Colombian neurosurgeon whose legacy is inextricably linked with the development of the neurosurgery specialty in Colombia. His detail-oriented approach to treatment complemented his reputation for mastery of the neurosciences. Never simply confined to the operating theater, this calm and considerate physician felt compelled to teach during his entire career. The result of his teaching made a lasting imprint on an entire generation of neurosurgeons who subsequently established a high standard of neurosurgical care in Colombia. A true pioneer, Bustamante comprehensively engaged in his field, from founding the country's first residency program in neurosurgery to successfully implementing technology in his procedures, performing many of Colombia's first neurosurgical interventions, and publishing extensively across various categories of medical science. This historical reflection highlights his enduring contributions to the field and considers his legacy through the witness testimony of many of his students and collaborators. The hope is that his contributions may be acknowledged in full, as he was a reserved person who never boasted of his own accomplishments. The authors also hope that those who did not have the opportunity to know him would be informed by the historical context of the development of Colombian neurosurgery and inspired by his conviction and altruism.

A history of Colombian neurosurgery: events, persons, and outcomes that have shaped the specialty in the country

The history of Colombian neurosurgery is a collective legacy of neurosurgeon-scientists, scholars, teachers, innovators, and researchers. Anchored in the country's foundational values of self-determination and adaptability, these pioneers emerged from the Spanish colonial medical tradition and forged surgical alliances abroad. From the time of Colombian independence until the end of World War I, exchanges with the French medical tradition produced an emphasis on anatomical and systematic approaches to the emerging field of neurosurgery. The onset of American neurosurgical expertise in the 1930s led to a new period of exchange, wherein technological innovations were added to the Colombian neurosurgical repertoire. This diversity of influences culminated in the 1950s with the establishment of Colombia's first in-country neurosurgery residency program. A select group of avant-garde neurosurgeons from this period expanded the domestic opportunities for patients and practitioners alike. Today, the system counts 10 recognized neurosurgery residency programs and over 500 neurosurgeons within Colombia. Although the successes of specific individuals and innovations were considered, the primary purpose of this historical survey was to glean relevant lessons from the past that can inform present challenges, inspire new opportunities, and identify professional and societal goals for the future of neurosurgical practice and specialization.

Moulder

PURPOSE

The intent of this mini review is to pay homage to Dr. John E. Moulder's long and successful career in radiation science with the Medical College of Wisconsin. This effort will be done from the perspective of his history of U.S. Government funding for research into the biological pathways involved in radiation-induced normal tissue injuries, especially damage to the kidneys and heart, and pharmacological interventions. In addition, the impact of his steady guidance and leadership in the mentoring of junior scientists, and the development of meaningful collaborations with other researchers will be highlighted.

CONCLUSION

Dr. John E. Moulder's contributions to the field of radiation research, through his strong character and reputation, his consistent and dedicated commitment to his colleagues and students, and his significant scientific advances, have been critical to moving the science forward, and will not be forgotten by those who knew him personally or through publications documenting his important work.

Environmental Impacts of Coal Combustion Residuals: Current Understanding and Future Perspectives

On-site solid-waste impoundments, landfills, and receiving water bodies have served as long-term disposal sites for coal combustion residuals (CCRs) across the United States for decades and collectively contain billions of tons of CCR material. CCR components include fine particulate material, minerals, and trace elements such as mercury, arsenic, selenium, lead, etc., which can have deleterious effects on ecosystem functioning and public health. Effects on communities can occur through consumption of drinking water, fish, and other aquatic organisms. The structural failure of impoundments, water infiltration, leakage from impoundments due to poor construction and monitoring, and CCR effluent discharges to water bodies have in the past resulted in harmful environmental impacts. Moreover, the risks posed by CCRs are present to this day, as coal continues to account for 11% of the energy production in the United States. In this Critical Review, the legacy of CCR disposal and the concomitant risks posed to public health and ecosystems are assessed. The resiliency of CCR disposal sites in the context of increased frequency and intensity of storm events and other hazards, such as floods and earthquakes, is also evaluated. We discuss the current state of knowledge on the environmental fate of CCR-derived elements, as well as advances in and limitations of analytical tools, which can improve the current understanding of CCR environmental impacts in order to mitigate the associated risks. An assessment of the 2015 Coal Ash Final Rule is also presented, along with needs to improve monitoring of CCR disposal sites and regulatory enforcement.

Memorials to John Snow - Pioneer in anaesthesia and epidemiology

John Snow was an English physician and a founding father of epidemiology, whose name is inextricably linked with tracing the source of the 1854 cholera outbreak in Soho, which killed over 600 people. Despite his recommendation to remove the water pump handle and thus reduce the spread of cholera, his theory of faecal-oral transmission was not widely believed until after his death. Furthermore, he also pioneered substantial achievements in the development of anaesthesia. He studied both chloroform and ether, improving the accuracy of their delivery. In his obstetric practice, he achieved the feat of obtaining satisfactory analgesia with a safer technique and is remembered for administering chloroform to Queen Victoria, during the delivery of her last two children. There are several interesting and unusual memorials to Snow, ranging from replica water pumps, blue plaques and a public house named after him. The most recent new memorial was erected in 2017, in his home town of York, which commemorates his origins and his subsequent contribution to curbing the cholera outbreak. All the memorials commemorate his achievements, which remain relevant today. Public health and epidemiology expertise is required in the current world of the COVID-19 pandemic, where his legacy remains as important as ever.

Conceptions of Legacy Among People Making Treatment Choices for Serious Illness: Protocol for a Scoping Review

BACKGROUND

Legacy-what one leaves behind and how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illnesses. A preliminary literature review suggests that patients facing serious illness consider legacy when making medical decisions, for example, forgoing expensive treatment with limited or unknown clinical benefit to preserve one's inheritance for their children. To date, very little is known about the conceptual foundations of legacy. No conceptual frameworks exist that provide a comprehensive understanding of how legacy considerations relate to patient choices about their medical care.

OBJECTIVE

The objective of this scoping review is to understand the extent and type of research addressing the concept of legacy by people facing serious illness to inform a conceptual framework of legacy and patient treatment choices.

METHODS

This protocol follows the guidelines put forth by Levac et al, which expands the framework introduced by Arksey and O'Malley, as well as the Joanna Briggs Institute Reviewer's manual. This scoping review will explore several electronic databases including PubMed, Medline, CINAHL, Cochrane Library, PsycINFO, and others and will include legacy-specific gray literature, including dissertation research available via ProQuest. An initial search will be conducted in English-language literature from 1990 to the present with selected keywords to identify relevant articles and refine the search strategy. After the search strategy has been finalized, 2 independent reviewers will undertake a 2-part study selection process. In the first step, reviewers will screen article titles and abstracts to identify the eligibility of each article based on predetermined exclusion or inclusion criteria. A third senior reviewer will arbitrate discrepancies regarding inclusions or exclusions. During the second step, the full texts will be screened by 2 reviewers, and only relevant articles will be kept. Relevant study data will be extracted, collated, and charted to summarize the key findings related to the construct of legacy.

RESULTS

This study will identify how people facing serious illness define legacy, and how their thinking about legacy impacts the choices they make about their medical treatments. We will note gaps in the literature base. The findings of this study will inform a conceptual model that outlines how ideas about legacy impact the patient's treatment choices. The results of this study will be submitted to an indexed journal.

CONCLUSIONS

Very little is known about the role of legacy in the treatment decisions of patients across the continuum of serious illness. In particular, no comprehensive conceptual model exists that would provide an understanding of how legacy is considered by people making decisions about their care during serious illness. This study will be among the first to construct a conceptual model detailing how considerations of legacy impact medical decision-making for people facing or living with serious illnesses.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40791.

Legacy gambling harms: What are they and how long do they last?

BACKGROUND AND AIMS

Legacy gambling harms are negative consequences of gambling that extend past periods of low risk, moderate risk and problem gambling. Gambling harm is typically measured within a 12-month timeframe and is often restricted to examining harm amongst active gamblers. The present research aimed to explore whether people experienced gambling harms 12 months or more after the resolution of at-risk or problem gambling, and how long these legacy harms lasted.

METHODS

An online survey was conducted in New Zealand with past and current gamblers and concerned significant others (CSOs) of gamblers, N = 1,240 (50.8% female), that asked them about both past and current gambling harms.

RESULTS

A majority of both gamblers and CSOs of gamblers indicated that they still suffered from gambling harm even after most of their behavioural issues with gambling had been resolved, 12+ months ago. Legacy gambling harms reduced over time, with harms diminishing most quickly in the early years, and having an average half-life of 4 years. Harms involving community-relationships, church involvement, and domestic and other violence resolved more quickly than others.

DISCUSSION AND CONCLUSIONS

Legacy harms are common among ex-problem gamblers and should be considered in any full accounting of the impacts of gambling.

CONCLUSION

Understanding the time course and persistence of legacy harms from gambling can provide gamblers, treatment professionals and public health experts with insights into how to address gambling's long-term consequences.

Hospitalized children's perceptions of legacy: 'A symbol of yourself that you leave behind'

BACKGROUND

Legacy building is a developmentally grounded, trauma-informed and family-centred psychosocial intervention designed to bolster patient and family resilience through collaborative activities and meaning making. However, little is known about the effects of these interventions, partially because of a lack of clarity regarding how children of different developmental levels understand the concept of legacy. Therefore, this study explored the ways in which hospitalized children defined the concept of legacy.

METHODS

Semi-structured interviews were conducted with 45 hospitalized children (ages 6 to 18 years) on the acute and critical care units of an academic children's medical centre. Interviews were audio-recorded and transcribed verbatim; transcripts were independently coded by at least two members of the research team using an inductive, line-by-line approach; and codes were categorized and assembled into four overarching themes, resulting in a developmental typology of the concept of legacy.

RESULTS

Participants described legacy as (1) concepts, actions or feelings motivated by the future; (2) represented through both tangible and intangible means; (3) informed by personal, educational, experiential and ideological sources; and (4) experienced as good, bad or neutral.

CONCLUSIONS

The findings of this study demonstrate that hospitalized children are aware of and can articulate an emerging concept of legacy - one that mirrors the progression of cognitive complexity shaped by their unique personal life and healthcare experiences. The developmental typology presented in this study can be a useful starting point for clinicians as they present and facilitate legacy building interventions throughout a child's hospital stay.

Helping Children Cope with Loss: Legacy Interventions for the Grieving Classroom

Early experiences of death and loss have a significant impact on children's coping and development across the lifespan, whether the deceased was a family member, friend, or even classmate. Given the sense of community and continuity that children often garner in schools, teachers are uniquely positioned to tailor and facilitate grief supports to meet the developmental and coping needs of their students in response to loss, especially in the case of a classmate's death. Legacy building interventions, though healthcare-derived, have internationally been applied to promote self-expression and meaning making for grieving children and families; the underlying theory and practice of such interventions may render them useful even in classroom environments. Combining art-based activities with storytelling and reflection, legacy building activities may promote awareness and understanding of death in children and adolescents while encouraging adaptive grief responses. This paper describes how teachers may apply legacy building interventions to support students experiencing the death of a classmate. Two sample curricular plans are provided, one targeted towards elementary school children, the other towards middle and high school students. Although these resources appear ready for immediate implementation, it is essential that teachers adapt them - based on their unique classroom, school system, and sociocultural context - to best meet the needs of grieving students.

Queer Monuments: Visibility, (Counter)actions, Legacy

This article synthesizes original comparative perspectives of visibility, (counter)actions, and legacy regarding queer monuments: public artworks dedicated to, and questioning or queering normativities around, the lives of LGBT+ people. It pursues a dialogic, interdisciplinary, and multisite and intercultural argument, drawing from approaches and preliminary insights from a scholarly project (Queer Memorials) and artist's project (Strange Inheritance) with topical case studies covering North America and Europe. After abductive ethnography, the analysis oscillates between theory/literature and scholarly and creative practice. It attends to the critical roles queer monuments have played in engaging with how sexual "others" have fallen in and out of place through social struggles, radical politics, and collective memory. The peer exchange provides a cross-case taxonomy of queer monuments' roles, navigating between sorrowful, celebratory, provocative, and informative types and values. It advocates both arts-based enquiry and practice as grounded pathways for narrating queer monuments' activist potential to memorialize, and visibilize, sexual and gender minorities and their overlapping rights in/to space.

A Love Rooted Deep in the Appalachian Mountains: One Part of the Legacy of Doug Scutchfield

F. Douglas Scutchfield, MD, died on Monday, May 23, 2022 in Lexington KY. I have known and worked with Doug for over 40 years and share my personal insights into how he created the Journal of Appalachian Health, one of his last great career adventures and a lasting legacy to his deep investment in the health and vitality of Appalachia and its people.

On We Go, with Hope: Remembering Our Founding Editor-in-Chief, Dr. F. Douglas Scutchfield

With the passing of our founding Editor-in-Chief, Dr. F. Douglas Scutchfield, the Journal of Appalachian Health team reflects on a life well lived and a monumental public legacy left behind. We thank "Scutch" for enriching the lives of so many, and we commit to growing the Journal in his honor.

Susan B. Baird, 1942-2022

Oncology Nursing Society (ONS) member, leader, and past editor of the Oncology Nursing Forum (ONF), Susan B. Baird, RN, MPH, MA, died on March 30, 2022, at the age of 79. Baird was a 40-year member of ONS, and from 1980-1990, she transitioned ONF to a journal, guiding it to the evidence-based resource enjoyed today. During the time most of us knew Susan, she referred to herself as Sue. For the last 20 years or so, she preferred Susan. I have used both in the following paragraphs.

Amplified Cardiopulmonary Recordings: Music Therapy Legacy Intervention with Adult Oncology Patients and Their Families-A Preliminary Program Evaluation

Background: Amplified cardiopulmonary recording (ACPR) is a unique music therapy intervention implementing recorded heartbeats with meaningful music. Although its clinical application has grown, there is limited research on the acceptability and usage by bereaved families. Objective: The research objective was to understand the frequency recipients engaged with ACPR after their loved one died. Design: A survey was undertaken with relatives of 191 adult patients who had participated in ACPR. Setting/Subjects: Bereaved loved ones of adult oncology patients who received care at the Norton Cancer Institute in Louisville, Kentucky, USA. Results: Out of the 191 participants, 73% of family members responded, 49% reported listening to their recording frequently, 31% listened to the recording at least once after receiving it, and 20% reported never listening. Conclusions: ACPR appears to have moderate acceptability and usage among bereaved family members, especially when created in the context of ongoing music therapy treatment. We recommend that this process-based music therapy intervention be studied further and offered proactively.

Little time, lasting impact: Bereaved caregiver perceptions of legacy in perinatal and infant loss

BACKGROUND

Legacy interventions are standard in most children's hospital, but little is known about how bereaved parents understand and describe the concept of legacy that these interventions are designed to document. The aim of this qualitative study was to understand the legacy experiences and perceptions of parents who have experienced perinatal or early infant (less than three months of age) loss.

METHODS

Grounded in constructionist epistemology and phenomenological qualitative traditions, ten bereaved parents completed an in-depth phenomenological interview regarding their perceptions of and experiences with the legacy of their deceased child. Interviews were transcribed verbatim and analyzed using an open, inductive coding process to illuminate the essence of participants' experiences.

RESULTS

Three themes were identified: 1) legacies are composed of memories and experiences that have a lasting effect on others; 2) healthcare experiences both generate and participate in infants' legacies; and 3) parents' legacy perceptions are shaped by cultural conceptions, spiritual beliefs, and grief experiences. Parents described experiences and interactions with community members and healthcare providers that honored or challenged their perceptions of their child's unique legacy.

CONCLUSIONS

In the context of perinatal or early infant loss, bereaved parents describe legacy as enduring, unique to each child and family, and heavily influenced by healthcare experiences and staff relationships. Parent-led, legacy-oriented interventions are needed in maternal/fetal, labor/delivery, and neonatal intensive care settings to support parent coping with loss.

Bereaved Families: A Qualitative Study of Therapeutic Intervention

Background

A child's death is the most stressful event and the most complex grief that families face. The process of psychological adaptation to the illness and death of a child is difficult due to a variety of emotional reactions. Parental grief had received the attention of researchers only in recent years when it became clear that this reality differs substantially from the general grief process.

Objective

This work aims to highlight the needs of bereaved parents; increase the specificity and effectiveness of the therapeutic approach to prevent complications in the process of loss-making; and find the recurrent thematic nuclei in the development of bereavement present in a therapeutic group of parents who have lost their child to an onco-hematological disease.

Method

Between 2011 and 2016, five therapeutic groups for the grief elaboration were made. The sample included a total of 50 parents of children who died from cancer between the ages of 0 and 21 years.Content analysis was carried out as a qualitative analysis method. The SAS^® Text Miner software (SAS Institute Inc, 2004) was used to read, interpret, classify and integrate the data from numerous sources.

Results

The development and consecutive interpretation of the 5 clusters have been carried out to analyze the related topics using the node "Topic Analysis" and requesting the subdivision into five topics. Four topics have been well defined. Clear topics are reducible to categories of emotional relief, tools, legacy, and unfinished business. The topic analysis provides interesting indications about the different interpretive journeys of the bereavement situation and offers ideas regarding the different types of social responses.

Conclusions

After reviewing the existing bibliography, we have confirmed the lack of specific literature on the problem of grief in parents whose children have died from cancer. Much research has shown that parents who lose a child to cancer want support, and there are still few studies on the most effective interventions for this group.

Methodological developments and practice in characterisation of unconventional and legacy waste

Radioactive waste management requires planned and systematic actions to provide confidence that the entire system, processes and final products will satisfy given requirements for quality. The characterisation process is dependent on setting clear characterisation objectives and gathering the right information to underpin the decisions that need to be taken to manage the waste safely. This paper reviews experience of characterisation of waste generated from past nuclear activities that were not conducted in compliance consistent with current criteria, or from unexpected situations that were not planned for. This experience shows that the development of a reliable and efficient characterisation and categorisation methodology is a common challenge for such wastes, referred to here as unconventional and legacy (UL) waste. Through the activites of the Nuclear Energy Agency Expert Group on the Characterisation of Unconventional and Legacy Waste, consideration has been given to widely used waste stream characterisation procedures and methods that were originally developed primarily for application in conventional decommissioning work. Although they provide a substantial basis for characterisation, there are various additional factors that commonly need to be taken into account in the case of UL waste. By analysing the challenges and lessons learned from a variety of case studies and other international experience, it has been possible to identify opportunities for adaptations and enhancements to these characterisation methologies, and these are set out and explained. The need for integration of waste characterisation with other aspects of strategic planning for UL waste management is discussed, including characterisation to address any non-radiological hazards. The analysed case studies have also highlighted the importance of developing a robust legislative and regulatory framework in parallel with an appropriate waste infrastructure to treat, store and dispose of UL waste. Finally, the basic features of a UL waste characterisation roadmap are presented, including the interactions within a wider UL waste management programme and key areas for further consideration and possible development. It is anticipated such work can be supported by continued international cooperation.

Impact of successive spring frosts on leaf phenology and radial growth in three deciduous tree species with contrasting climate requirements in central Spain

Rear-edge tree populations forming the equatorward limit of distribution of temperate species are assumed to be more adapted to climate variability than central (core) populations. However, climate is expected to become more variable and the frequency of climate extremes is forecasted to increase. Climatic extreme events such as heat waves, dry spells and spring frosts could become more frequent, and negatively impact and jeopardize rear-edge stands. To evaluate these ideas, we analyzed the growth response of trees to successive spring frosts in a mixed forest, where two temperate deciduous species, Fagus sylvatica L. (European beech) and Quercus petraea (Matt.) Liebl. (sessile oak), both at their southernmost edge, coexist with the Mediterranean Quercus pyrenaica Willd. (Pyrenean oak). Growth reductions in spring-frost years ranked across species as F. sylvatica > Q. petraea > Q. pyrenaica. Leaf flushing occurred earlier in F. sylvatica and later in Q. pyrenaica, suggesting that leaf phenology was a strong determinant of spring frost damage and stem growth reduction. The frost impact depended on prior climate conditions, since warmer days prior to frost occurrence predisposed to frost damage. Autumn Normalized Difference Vegetation Index data showed delayed leaf senescence in spring-frost years and subsequent years as compared with pre-frost years. In the studied forest, the negative impact of spring frosts on Q. petraea and especially on F. sylvatica growth, was considerably higher than the impacts due to drought. The succession of four spring frosts in the last two decades determined a trend of decreasing resistance of radial growth to frosts in F. sylvatica. The increased frequency of spring frosts might prevent the expansion and persistence of F. sylvatica in this rear-edge Mediterranean population.

Management and regulatory supervision of legacy sites and radioactively contaminated lands in Republic of Kazakhstan

The safe management and disposal of radioactive waste (RW) arising from the nuclear legacy, as well as newly generated RW, are key problems. Their solution will have important implications for nuclear energy development, the introduction of other radiation technologies, and their public perception. In the framework of the cooperation between the Committee of Atomic and Energy Supervision and Control (CAESC) of the Ministry of Energy of the Republic of Kazakhstan and the Norwegian Radiation and Nuclear Safety Authority (DSA), work has been carried out to analyse the current state of nuclear and radiation safety in the Republic of Kazakhstan. The analysis was based on identifying gaps in national legislation and the assessment of corresponding threats in this area. Proposals for their elimination were developed, taking into account international experience and International Atomic Energy Agency recommendations. Analysis of the current situation in the Republic of Kazakhstan showed that at present the RWs are not properly regulated within an up-to-date regulatory framework. Currently, a list of key by-laws is being developed, which will support the provisions of a new law on RW management, and work is underway to adopt the already developed and drafted regulatory documents. Within the framework of the CAESC-DSA cooperation, the priority tasks established for 2021-2024 include the development of regulatory documents for the rehabilitation of uranium heritage sites, site selection for new nuclear facilities, and the management of nuclear materials for certain types of installations and manufactures. Practice has shown the need to use the advanced international experience and common approaches developed internationally, to develop and apply long-term and reliable solutions for the management of RW and nuclear legacy facilities and territories. The solution of these problems concerns not only scientists, technologists, and employers of the nuclear industry, but requires their cooperation with politicians, regulatory authorities, and the general population. The importance of sharing international experience to understand and solve these challenges is highlighted.

Educate Kermit Roosevelt Through Sport Hunting and Train Him for Government Missions. Roosevelt Scientific Mission to English Equatorial Africa in 1909

The practice of sport hunting in colonized areas presents a set of knowledge and techniques indispensable to self-control and the domination of territories elsewhere by colonial empires, by their leaders and, more generally, by the political elites of the Northern states. During his scientific mission to English Equatorial Africa in 1909, Theodore Roosevelt responded to a double commission from the Smithsonian Institute and the American Museum in Washington. In this African mission, he brought and trained his youngest son Kermit, aged 20, in an initiatory journey. This article proposes to study this ritual of passage and the practice of sport hunting in the English colonial space as a revelation of the socio-racial hierarchies at work in the territories dominated by the English Empire.

Management and cleanup of legacy radium-contaminated sites in the United States

The hazards associated with radium-containing materials were largely unknown when they were first introduced into household and other products over a century ago. Radium was also originally thought to have beneficial health properties, leading to confusion amongst the public about the safety of radium in household products and food items. When the adverse health effects associated with radium were discovered and became well known, radium products became unpopular and were prohibited in some countries. In the United States, after the hazards associated with radium became known, radium was first regulated by individual states in the late 1920s and early 1930s. Later, the US Nuclear Regulatory Commission (NRC) was given a role in the regulation of discrete sources of radium with the passage of the Energy Policy Act of 2005. After passage of the Act, the NRC began to systematically identify sites around the country where radium was used and reached out to site owners to determine whether existing radium contamination could pose a risk to public health and safety and the environment. The NRC devised a graded approach in response to its new regulatory responsibilities to address potential public health and safety issues at legacy radium sites. By September 2019, the NRC had dispositioned all the sites that were identified as having potential contamination from historical radium within its regulatory purview in non-Agreement States. The staff worked with site owners and federal, state and local officials, as needed, to properly disposition the sites to ensure that each site either meets the applicable criteria for unrestricted use or has controls in place to limit access during remediation so that no site poses an unacceptable risk to public health and safety and the environment.

Impact of the Paralympic Games on the Beliefs of Children with Physical Disabilities Engaging in Sports and Physical Activities: A Chinese Perspective

The purpose of this qualitative study was to explore the beliefs of Chinese children with physical disabilities engaging in sports and physical activity (PA), and the impact of the Paralympic Games on these beliefs. Five Chinese children with physical disabilities (female = 2, male = 3) were recruited for participating in the workshops of the Paralympic Games and PA, and received individual semi-structured interviews before and after the workshop implementations. Interview transcripts were analysed and presented as descriptive summaries. Three themes emerged based on the analysis of the participants' interview data: (1) shocked, knowledgeable, and useful; (2) willingness to try, and (3) hope to obtain support. Results indicated that children with physical disabilities in this study acknowledged the positive outcomes of participating in the workshops of the Paralympic Games on the sports and PA engagement attitude change. However, children with disabilities also expressed that they need more related knowledge and information. The results of the study revealed that impairment and contextual factors (i.e., lack of support from family and physical education teachers, unsafe environments, and negative attitudes of peers without disabilities) were barriers to sports and PA engagement among children with physical disabilities in this study.

Sport Events for Sport Participation: A Scoping Review

Research on sport participation impacts from sport events has been sporadic. This scoping review assesses the current state of literature that addresses impacts, legacies, and leveraging of sport events for sport participation outcomes and the gaps in terms of study context and research designs. Two systematic approaches of article identification were performed: a traditional database search and a systematic manual search. Studies on sport participation outcomes from events mainly focused on mega sport events and adult populations, with the majority employing cross-sectional data and quantitative methods. The use theoretical of frameworks is limited and inconsistent. There is a need for longitudinal investigations, as well as more focus on youth populations, participant events, and smaller-sized events to advance the research agenda for sport participation outcomes from sport events.

Innovation for Positive Sustainable Legacy From Mega Sports Events: Virtual Reality as a Tool for Social Inclusion Legacy for Paris 2024 Paralympic Games

There is significant interest in how sports events and their associated legacies could act as a platform to address global challenges and engender social change. The United Nations (UN) has acknowledged the important role that sport plays in supporting the UN 2030 Agenda for Sustainable Development and the Olympic movement could be argued as central to that objective. Yet critical questions and concerns have been raised about the growing expenditure, viability, long term legacy, and impacts of mega sports events such as the Olympic Games. While much evidence has focused on the challenges of creating legacy for Olympic Games, there is considerably less literature on understanding the Paralympic context. The purpose of this paper is to discuss the role of innovation in creating legacy from MSEs and propose a theoretical and methodological plan for such research. Innovation, a key driver in organizational performance, is suggested as essential to defining, planning for and measuring legacy. We specifically examine the potential of virtual reality (VR) as a technological innovation which can help create a social inclusion legacy in the context of Paris 2024 Olympic/Paralympic Games. A conceptual model is developed, which identifies legacy as a "wicked problem", and this paper discusses the importance of innovation with regards to legacy, by suggesting a new application for VR technology in the context of legacy related to social inclusion. Information technology is a valuable facilitator of social inclusion for individuals with a disability. We specifically examine the potential of VR as a technological innovation which can help create legacy through influencing unconscious biases (symbolic ableism) toward diversity such as disability, gender, and race.

Then and now: the legacy and future of attachment research

Attachment theory rescued psychology from the choice between an untestable psychoanalytic, drive reduction theory and behaviorist positions that were incapable of accounting for development. Theory and research on attachment over the last 5 decades advanced knowledge on vital topics such as the emergence of the self, emotion regulation, resilience, and mental representations. The success of the theory led to broad applications both within and outside of academia. Now is a useful time to appraise this body of work and to consider future directions. The book, "Cornerstones," and the two target articles in this special issue provide an important start to this process, suggesting a number of potentially fruitful directions. Some of the challenges associated with these suggestions are addressed in this commentary.

The history of neurosurgery at the University of Nebraska Medical Center

The Department of Neurosurgery at the University of Nebraska Medical Center has grown considerably from one neurosurgeon in 1923 into a first-class department with diverse subspecialty care and innovative faculty. Founding neurosurgeon Dr. J. Jay Keegan, a student of Harvey Cushing, instituted a legacy of clinical and research excellence that he passed on to his successors. The department created a lecture series to honor Keegan's pioneering techniques and impact in the field, featuring prominent neurosurgeons from across the country. Keegan's successors, such as Dr. Lyal Leibrock, grew the department through a unique partnership with private practice. The current faculty has continued the tradition of exceptional resident training and innovative patient care.

Rethinking Mass-Gathering Domains for Understanding Patient Presentations: A Discussion Paper

AIM

The aim of this paper is to further develop an existing data model for mass-gathering health outcomes.

BACKGROUND

Mass-gathering events (MGEs) occur frequently throughout the world. Having an understanding of the complexities of MGEs is important to determine required health resources. Environmental, psychosocial, and biomedical domains may be a logical starting point to determine how data are being collected and reported in the literature; however, it may be that other factors influencing health resources are not identified within these domains.

METHOD

Based on an exhaustive literature synthesis, this paper is the final paper in a series that explores the collection of variables that impact biomedical presentations associated with attendance/participation in MGEs.

FINDINGS

The authors propose further evolution of the Arbon model to include the addition of several domains, including: event environment; command, control, and communication (C3); public health; health promotion; and legacy when reporting the health outcomes of an event.

CONCLUSIONS

Including a variety of domains that contribute to an MGE allows for formal evaluation of the event, which in turn informs future knowledge and skill development for both the event management group and the wider community.

Physical Activity Among Urban-Living Middle-Aged and Older Japanese During the Build-Up to the Tokyo Olympic and Paralympic Games: A Population Study

This research examines physical activity (PA) parameters among urban-living middle-aged and older Japanese during the Tokyo Olympic build-up period. Population sampling was employed, and an online survey was administered with 4,000 adults across Japan's five largest cities. The International Physical Activity Questionnaire-Short Form constituted the main outcome variable, with auxiliary measures of Olympic interest and engagement, readiness for PA behavior change, perceived environmental barriers, and demographic information. Despite interest in the Olympics (>60% moderate-high interest), planned engagement with the event was low (>70% planned passive engagement). Higher levels of interest and planned engagement were both significantly correlated with greater self-reported PA participation (p < .001). Across the sample, the PA levels were in the low-moderate range (990 metabolic equivalent of task-min/week), with significant variations observed by the age-cohort and geographic area (p < .001). Age-cohort and geographic variations were also identified with regard to readiness for PA behavior change and perceived environmental barriers to activity (p < .001). Older age (65 years and above) and host city (Tokyo) residence emerged as correlates of higher levels of PA, greater readiness for behavior change, and fewer reported barriers to participation. These findings have implications for Olympic legacy management and successful transitions from middle age to later life in Japan.

Defining Legacy: The Perceptions of Pediatric Health Care Providers

Legacy building interventions like plaster hand molds are offered in most children's hospitals, yet little is known about how the concept of legacy is understood and described by pediatric health care providers. Therefore, this study explored pediatric health care providers' perceptions of legacy at an academic medical center to ensure that future legacy interventions are evidence-informed and theoretically grounded. An electronic survey featuring three open-ended questions and two multiple-choice questions with an option for free text response was completed by 172 medical and psychosocial health care providers. Analysis yielded four themes: (1) legacy is intergenerational, enduring, and typically associated with end-of-life; (2) legacies articulate the impacts on others for which one is known and remembered; (3) legacies can be expressed through tangible items or intangible qualities; and (4) legacies are informed and generated by family relationships and work experiences. By understanding legacy as a personally and professionally contextualized experience, health care providers can better assess and meet the legacy needs of hospitalized pediatric patients and families.

Dignity Therapy in Pediatrics: A Case Series

Objective: To report our first case series of Dignity Therapy modified for a pediatric palliative care population. Background: Dignity Therapy has been utilized successfully with terminally ill adult patients to help restore a sense of dignity and personhood as well as cope with existential distress near the end of life. To our knowledge, there are no published reports of this treatment modality in pediatric patients. Methods: The authors report the experience of a single-center case series of Dignity Therapy in a pediatric palliative care population. The adult Dignity Therapy process was adapted to fit the pediatric population and their families. Modifications are explained in some detail, and specific cases are shared to illustrate the process. The goal of this case series is to report on the application of Dignity Therapy to the pediatric population. Setting/subjects: Inclusion criteria for the cases series consisted of children and their families who were aware that death may occur soon, were English speaking, admitted to the hospital, and receiving care from the palliative care service. Results: Eight patients or their caregivers have completed Dignity Therapy thus far through our program. Four consented to publication of their experience. Three patients were adolescents and told their own story and the story of one younger nonverbal child was told by her family. All four participants reported that the intervention was acceptable and expressed gratitude for their final generativity document. No patient or family reported distress or negative effects from participation in Dignity Therapy. Conclusions: This case series describes how Dignity Therapy is possible with adaptations in the pediatric population, and how Dignity Therapy by proxy may be possible for caregivers of patients unable to tell their own story.

Shoulder arthroscopy: a bridge from the past to the future

This article constitutes the text of the Codman Lecture, delivered by the author to the attendees of the International Congress of Shoulder and Elbow Surgeons on September 19, 2019, in Buenos Aires, Argentina.

Ethical considerations when conservation research involves people

Social science is becoming increasingly important in conservation, with more studies involving methodologies that collect data from and about people. Conservation science is a normative and applied discipline designed to support and inform management and practice. Poor research practice risks harming participants and, researchers, and can leave negative legacies. Often, those at the forefront of field-based research are early-career researchers, many of whom enter their first research experience ill-prepared for the ethical conundrums they may face. We draw on our own experiences as early-career researchers to illuminate how ethical challenges arise during conservation research that involves human participants. Specifically, we considered ethical review procedures, conflicts of values, and power relations, and devised broad recommendations on how to navigate ethical challenges when they arise during research. In particular, we recommend researchers apply reflexivity (i.e., thinking that allows researchers to recognize the effect researchers have on the research) to help navigate ethical challenges and encourage greater engagement with ethical review processes and the development of ethical guidelines for conservation research that involves human participants. Such guidelines must be accompanied by the integration of rigorous ethical training into conservation education. We believe our experiences are not uncommon and can be avoided and hope to spark discussion to contribute to a more socially just conservation.

PROMIS Versus Legacy Patient-Reported Outcome Measures in Patients Undergoing Surgical Treatment for Symptomatic Acetabular Dysplasia

BACKGROUND

No previous study has investigated how the Patient-Reported Outcomes Measurement Information System (PROMIS) performs compared with legacy patient-reported outcome measures in patients with symptomatic acetabular dysplasia treated with periacetabular osteotomy (PAO).

PURPOSE

To (1) measure the strength of correlation between the PROMIS and legacy outcome measures and (2) assess floor and ceiling effects of the PROMIS and legacy outcome measures in patients treated with PAO for symptomatic acetabular dysplasia.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This study included 220 patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) pain, HOOS activities of daily living (ADL), modified Harris Hip Score (mHHS), PROMIS pain, and PROMIS physical function subsets, with scores collected preoperatively and/or postoperatively at a minimum 12-month follow-up. The change in mean scores from preoperatively to postoperatively was calculated only in a subgroup of 57 patients with scores at both time points. Distributions of the PROMIS and legacy scores were compared to evaluate floor and ceiling effects, and Pearson correlation coefficients were calculated to evaluate agreement.

RESULTS

The mean age at the time of surgery was 27.7 years, and 83.6% were female. The mean follow-up time was 1.5 years. Preoperatively, neither the PROMIS nor the legacy measures showed significant floor or ceiling effects. Postoperatively, all legacy measures showed significant ceiling effects, with 15% of patients with a maximum HOOS pain score of 100, 29% with a HOOS ADL score of 100, and 21% with an mHHS score of 100. The PROMIS and legacy instruments showed good agreement preoperatively and postoperatively. The PROMIS pain had a moderate to strong negative correlation with the HOOS pain (r = -0.66; P < .0001) and mHHS (r = -0.60; P < .0001) preoperatively and the HOOS pain (r = -0.64; P < .0001) and mHHS (r = -0.64; P < .0001) postoperatively. The PROMIS physical function had a moderate positive correlation with the HOOS ADL (r = 0.51; P < .0001) and mHHS (r = 0.49; P < .0001) preoperatively and a stronger correlation postoperatively with the HOOS ADL (r = 0.56; P < .0001) and mHHS (r = 0.56; P < .0001).

CONCLUSION

We found good agreement between PROMIS and legacy scores preoperatively and postoperatively. PROMIS scores were largely normally distributed, demonstrating an expanded ability to capture variability in patients with improved outcomes after treatment.

Karl Jaspers and Karl Popper: the shared legacy

Jaspers and Popper have nothing in common beyond the legacy of Immanuel Kant's philosophy. Popper dismisses Jaspers 'existentialism' as nihilistic and historicist; Jaspers never cites Popper. Jaspers describes Kant as 'the philosopher for me'; Popper is an unorthodox Kantian whose critical rationalism put the finishing touch to Kant. For Kant, knowledge is not a simple copy of reality, but begins with reason's questioning. Jaspers and Popper too insist that theory has priority over observation. For Jaspers, 'there is already theory in every fact'; for Popper, 'every statement has the character of a theory'. Science begins with metaphysical Ideas which become scientific when tested in experience. They differ in Popper's rejection of induction in favour of falsification, while Jaspers tacitly accepts induction.

Surgical neurology: Harvey Cushing's endangered legacy

As it does periodically, the United States healthcare system is, yet again, undergoing a period of change on multiple fronts, including internal initiatives in education, quality, and the workforce, as well as external pressure responding to changes in reimbursement and oversight. In such times, looking back at the foundations of our specialty is helpful, allowing often-beleaguered neurosurgeons to reflect upon what it means to be a neurosurgeon, and how they can be assured that our specialty will continue to flourish in the future. Harvey Cushing envisioned, espoused, and developed neurological surgery as a "special field"-a comprehensive, encompassing, and distinct discipline that studies the nervous system and manages neurological disorders. It provides surgical intervention for the treatment of neurological disorders; it by no means was meant to be developed as a mere technical or procedural skill; it is neither a subspecialty of surgery nor a branch of neurology; it is a "special field" that has flourished to become a crown jewel in the realm of medicine. Herein is a perspective that brings the inception and future of this concept to light. A specialty that is to live and flourish should stand on and recognize its roots.