3.9: Genetic Approaches to Examine the Intact and Living Brain
Labeling the Living Brain
Owing to the complexity of the mammalian brain, it has remained a major challenge to decipher the patterns of connectivity made onto and by newborn neurons as they integrate into circuits of the adult brain. With major advances in both molecular genetics and light microscopy, our ability to query not only neuronal morphologies, but also the molecular and cellular composition of individual neurons and their associated synaptic networks has become possible.
Arguably, one of the most influential contributions to contemporary neuroscience has been the use of fluorescent proteins (FPs) and their targeted expression in living neurons of the mammalian brain tissue. The wide array of FPs available provides an ever-expanding toolbox of vital reporters and gene expression tags. Applications for these proteins range from vital reporters expressed throughout the cytoplasm to subcellular protein fusion tags, which together can be used to monitor the process of circuit integration in vivo using both electrophysiological methods and fluorescent imaging.
Beyond merely marking cells for identification, a number of other methods have been developed to exploit the vital properties of FPs to investigate neuronal properties. For example, superecliptic pHluorin, which fluoresces at neutral pH but is quenched at acidic pH, can be used to monitor the trafficking and exchange of intracellular compartments within neurons. This variant allows direct imaging of membrane dynamics, exocytosis and endocytosis of synaptic receptors, and neurotransmitter release in vitro and in vivo . More recently, a new method termed GFP reconstitution across synaptic partners (GRASP) shows promise for revealing synaptic interactions between contacting neurons. By tethering split GFP fragments to separate pre- and post-synaptic proteins, reconstitution of GFP fluorescence can be observed when genetically targeted cells form synaptic pairs. Although this technology has been successfully applied to reveal invertebrate synapses, it has yet to be demonstrated in rodents ( Gordon and Scott, 2009 ).
The range of FP reporters for visualizing neuronal morphologies, cellular dynamics, and synapse function continues to expand. However, perhaps the single-most limiting factor for using FPs in neuroscience is our incomplete knowledge of neuronal gene regulation. Often transgenic reporters fail to recapitulate endogenous patterns of gene expression, or such patterns are too broad to identify neuronal subtypes with cellular precision.
Trans-Synaptic Circuit Tracing
A major goal toward understanding mechanisms of neuronal development, synapse formation, and circuit wiring has been to elucidate nodes and patterns of synaptic connectivity. A creative angle to address this challenge has been the incorporation of genes encoding FPs and FP-fusion proteins into neurotropic viral vectors, which show the innate ability to infect neurons and trans-synaptically spread throughout the nervous system ( Kuypers and Ugolini, 1990 ; Callaway, 2008 ).
Two types of viruses that have been broadly employed for this purpose include rabies and herpes. Herpes viruses belong to a family of double-stranded DNA viruses, while rabies belongs to a family of negative-strand RNA viruses ( Voyles, 1993 ). Although evolutionarily different, they are both endowed with the unique ability to bind to and infect neuronal cells. This cell type-specific infectivity is conferred to the viruses via their mature enveloped coat particles, which are made of both host membrane and virally encoded glycoproteins. The composite envelope proteins are the determinants that mediate neuronal membrane recognition and subsequent neuron-to-neuron infection by binding to membrane surface receptors.
Herpes viruses have been used to label neural circuits for years. Two common tracing strains are herpes simplex virus-1 (HSV-1; Lilley et al., 2001 ) and pseudorabies virus (PRV; Enquist, 2002 ). Both of these variants predominantly spread in a retrograde direction, and each has been effectively applied to dissect synapse and circuit connections in the rodent brain ( Callaway, 2008 ). However, one limitation to using the herpes viruses for circuit analysis is polysynaptic spreading. Due to the vast cohort of cell types within brain tissue, the number of synapses formed on each of those cells, and the high degree of interconnectivity in intact neural circuits, this approach still poses a challenge to dissect precise patterns of neural connectivity. To simplify trans-synaptic circuit analysis, Wickersham et al. (2007b) devised a clever coat protein complementation strategy that allows for monosynaptic tracing of neuronal connections using a pseudotyped rabies virus (RV). Not to be confused with PRV (which as stated above is actually a herpes virus), pseudotyping a viral particle refers to synthetically modifying the viral envelope to recognize a foreign receptor not normally present on the membranes of mammalian neurons. The strategy will be briefly discussed below, and for further reference also see Wickersham et al. (2007a) , Arenkiel and Ehlers (2009) , Hasenstaub and Callaway (2010) .
The RV gene encoding its glycoprotein (termed G) has been the primary target for genetic modification and RV vector engineering. Removal of G from the RV genome renders the virus both incapable of generating infective particles and replication incompetent. However, even in the absence of the native glycoprotein gene, RV is still capable of expressing its genome. Thus, G can be replaced with sequences encoding FPs or FP-tagged biomolecules to generate RV vectors for vital reporter expression ( Wickersham et al., 2007a ). To make these replication incompetent viruses useful for circuit tracing studies, they must be “armed” by providing an envelope in trans by propagating and packaging the particles in vitro using cell lines engineered to synthesize the required glycoprotein.
To perform monosynaptic circuit tracing and target FP-expressing RV to desired neuronal subsets, the particles can first be pseudotyped with the foreign coat protein EnvA from avian sarcoma leukosis virus, which specifically binds to a class of avian membrane proteins called TVA receptors ( Barnard et al., 2006 ). Genetic targeting of neuronal subsets for TVA expression directs RV infection to only those neurons. To facilitate monosynaptic tracing, Wickersham et al. (2007a) added a clever twist on this approach. By introducing a plasmid that encodes the wildtype RV G-protein, the disarmed EGFP-expressing virus is now able to undergo one round of subsequent infection to presynaptic partners of TVA-targeted neurons. Since only the initially infected neuron contains G, viral spread ceases after one round of monosynaptic jumping. Including a plasmid encoding a red FP allows the cell originally targeted for infection to be identified amongst the monosynaptic network of GFP labeled cells (Figure \(\PageIndex{1}\)). Of course it must be considered that true monosynaptic tracing is dependent on targeting individual neurons for the expression of G. If for example synaptically coupled cells both harbor G, but only one of them serves as the primary source cell of TVA-mediated infection, then viral spread can become multisynaptic through subsequent rounds of viral packaging in presynaptic partners. Monosynaptic tracing control thus depends directly upon the precision of neuronal targeting for the RV tracing components.
Figure \(\PageIndex{1}\).
Engineering and pseudotyping rabies virus (RV) for transneuronal tracing.
(A)
RV can be genetically engineered to express EGFP by replacing the genomic sequence encoding the G coat protein. The genetically modified G-deletion mutant RV must be propagated in vitro to supply a coat protein. The particle can thus be pseudotyped by providing a foreign coat protein such as EnvA, which originates from the avian leukosis virus and binds specifically to it its cognate receptor TVA. EnvA pseudotyped RV can be used to selectively infect neurons that have been genetically targeted for TVA expression. By including additional constructs that encode the wildtype G-capsid protein and a red-colored “cell fill”
(B)
, the modified RV can be genetically targeted to individual neurons for restricted circuit mapping and monosynaptic tracing
(C).
Since no endogenous receptors exist in the mammalian brain for EnvA, only neurons that are programmed to express TVA are capable of being infected by the EnvA pseudotyped virions. Because the wildtype G-protein sequence has been deleted from the RV genome, G must be supplied by complementation to allow trans-synaptic spread from the neurons targeted for infection.
(D)
Viral spread ceases monosynaptically due to the absence of G in unmodified neuronal populations.
This new technology now makes it feasible to dissect complicated patterns of neuronal connectivity with synaptic precision ( Stepien et al., 2010 ; Weible et al., 2010 ). Targeting adult-born neurons for monosynaptic circuit tracing holds certain promise toward elucidating the numbers, types, and synaptic inputs that might usher and/or promote the formation and maintenance of functional circuit integration. Unfortunately however, much needs to be learned about the viral mechanisms of infectivity, trans-synaptic propagation, and replication to make viral tracing methods broadly applicable for detailed circuit analysis throughout the nervous system. For example, one major limitation to viral-mediated circuit tracing using either HSV or RV type vectors is the inevitable deterioration of neuronal cell health with time ( Callaway, 2008 ). Whereas the HSV particles show rapid and high levels of expression within 1–2 days, they also show a lytic-type phase of replication that induces neuronal loss within 1–2 weeks. Although most neurons appear to tolerate RV infection for longer periods of time, they too eventually show signs of dysfunction and poor health beyond 2 weeks. In addition, not much is known regarding the exact tropism for the various viruses to infect particular subtypes of neurons. Although it is clear that viral particles can cross axo-dendritic, dendro-dendritic, glutamatergic, and GABAergic synapses ( Willhite et al., 2006 ; Wickersham et al., 2007b ; Stepien et al., 2010 ; Miyamichi et al., 2011 ; Rancz et al., 2011 ), the different efficacies of transfer have not been determined. Preferential binding of viral particles to different types of presynaptic proteins must exist, which would ultimately result in more efficient transfer of viruses between certain synaptic pairs. This information is currently unknown, thus it remains a challenge to reliably perform unbiased quantitative circuit analysis using viruses over extended periods of time.
Although current trans-synaptic circuit tracing methods are in their infancy, with further understanding of the viral mechanisms, and a subsequent “re-tooling” of existing vectors, one can easily imagine that this experimental avenue for intact circuit mapping will become indispensable. Moreover, this methodology holds definite promise to address outstanding questions in adult neurogenesis, ranging from identification of the types of connections that are dynamically made and broken during circuit development, to exposing the complete cohort of input types that are observed in mature circuits within the intact brain.
Manipulating Cell and Circuit Activity
Earmarking neuronal subsets and their associated networks for has been invaluable toward our current understanding of neuronal morphologies and circuit architecture. However, to fully understand the cellular and molecular mechanisms that guide adult-born neuron synapse formation and circuit integration, we must be able to probe neuronal connectivity. Recent advances in genetically encoded actuators now provide this possibility. Technologies such as heterologous receptor or channel expression, optogenetics, and genetically encoded synaptic toxins are beginning to allow functional circuit mapping with synaptic precision ( Luo et al., 2008 ; Arenkiel and Ehlers, 2009 ; Figure \(\PageIndex{3}\) ). By targeting pre- or post-synaptic cell types for activity manipulations, coupled with functional imaging and/or electrophysiological recordings, it is now possible to genetically dissect circuit nodes by monitoring evoked synthetic output responses. Some of the earliest efforts to genetically control neuronal output relied on engineered expression of heterologous receptors in neurons that normally do not show their presence. For example, expression of modified opiate receptors in the brains of transgenic mice showed that introducing synthetic exogenous ligands could activate neuronal subsets ( Zhao et al., 2003 ). To date, numerous variations on this theme have proven effective for both driving neuronal excitability and inhibition. Complementary strategies to these methods have been to genetically express small-molecules for inactivation of synaptic transmission ( Karpova et al., 2005 ), or toxins that disrupt synaptic transmission ( Harms et al., 2005 ; Ehlers et al., 2007 ).
Genetic strategies to mark and manipulate neurons and circuits
Figure \(\PageIndex{3}\).
(A)
Neurons can be targeted for heterologous receptor expression. These foreign receptors can be either directly or indirectly gated by application of exogenous ligands (depicted as red ovals and purple diamonds). Left: heterologous receptor activation via application of synthetic ligands can be used to change a neuron’s ionic equilibrium and thus firing properties. Right: depending on molecular properties, exogenous ligands spread variably throughout brain tissue. All neurons expressing the heterologous receptors are capable of being activated and driving target cell responses (represented as green circles).
(B)
Expression of light-gated channels can be used to modulate neuronal firing with photons. Left: ChR-2 is a non-selective cation channel that responds optimally to blue light. Photostimulating this channel results in positive inward currents, depolarization, and neuronal firing. NpHR is a photoactive chloride pump that responds optimally to greenish-yellow light. Photostimulating this pump protein results in negative inward currents, hyperpolarization, and neuronal silencing. Right: FP-fusion reporters can be used to identify cells that express photoresponsive proteins (represented by blue coloring). Only neurons expressing the photoresponsive channels and receive photons show light activated modulation, whereas downstream circuit targets can be monitored for post-synaptic photo responses (green coloring).
(C)
Targeted expression of synaptic toxins in neurons can be used to block synaptic vesicle release and inhibit neurotransmission to post-synaptic targets. TTC, tetanus toxin.


13.10.4: Implementation
Once the program has been designed, it’s time to actually put it into action. Implementing a program may require many smaller administrative tasks, as well as staying organized so as to make sure that the different pieces of the program come together smoothly. For example, if personnel must be hired, it may be necessary to have the human resources (HR) department post a job description, interview potential candidates, and then finalize the hiring process. Grant funds may take time to be released, and then be encumbered (assigned) to different departments. Equipment may need to be purchased, locations and rooms may need to be reserved or rented, and staff may need to be trained. Once the program gets started these different moving parts may need to be monitored and outcomes tracked or tested at different times. Often program planners will use logic models to help them organize the steps in the process, or a Gantt chart to give them an overview of priority tasks (McKenzie et al., 2017). See Table \(\PageIndex{1}\) for an example of a Gantt chart.
|
Tasks First Year |
J |
F |
M |
A |
M |
J |
J |
A |
S |
O |
N |
D |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Conduct needs assessment |
x |
|||||||||||
|
Design program (goals, objectives, activities) |
x |
|||||||||||
|
Create pilot program |
x |
|||||||||||
|
Procure resources for next phase (personnel, equipment, locations) |
x |
x |
x |
|||||||||
|
Create marketing tools |
x |
|||||||||||
|
Market program |
x |
x |
x |
x |
x |
x |
x |
|||||
|
Pilot test program (6 weeks) |
x |
x |
||||||||||
|
Assess pilot program |
x |
|||||||||||
|
Conduct phase 1 program |
x |
x |
x |
|||||||||
|
Conduct phase 2 (full) program |
x |
x |
x |
x |
||||||||
|
Assess and evaluate program |
x |
Running a smaller version of the program, or pilot program, can help identify challenges or issues early on. Pilot programs can be run at a single site instead of multiple locations, and include fewer participants, and be conducted for a shorter period of time. The pilot program can then be assessed, and necessary changes can be made to the program plan before expanding it to full implementation. For example, perhaps the pilot of a senior fall prevention program is conducted at a local community center, but the participants have trouble getting transportation to attend the program classes. This might inform the program planner that the location needs to be changed, or that transportation needs to be provided in order for the full program to be successful. After the pilot program and assessment, the program might have a phase-in process where a slightly larger version of the program is implemented, then expanded. Phasing-in can be beneficial on several levels: not all of the resources have to be ready at the same time, and challenges or barriers can be addressed before they affect the program at large. The process of phasing-in can be done by adding locations, by expanding the number of participants or the level of ability, and/or by adding activities of the program. For example, a smoking-cessation program might begin with support group meetings, then add stress management classes. Or a program might begin in one neighborhood park, then expand to others across the city (McKenzie et al., 2017, Seabert et al., 2021).


1.8: Introduction to Communication and Professionalism
What you’ll learn to do: write professionally and effectively in your college communications
Whether you are sending an email to your adviser, writing a paper, or delivering a presentation, effective communication is essential to your success in college. College will require you to communicate professionally and effectively in a range of different contexts.
In this section, you will learn about some basic strategies for improving your communication skills in college, including preparing for writing assignments, avoiding plagiarism, writing emails, and participating in discussions.
Contributors and Attributions
CC licensed content, Original
- Modification, adaptation, and original content. Authored by : Lumen Learning. License : CC BY: Attribution
CC licensed content, Shared previously
- Improving Communication Skills. Provided by : Cengage. Located at : https://florida.theorangegrove.org/og/file/86100f79-955b-41f8-ac7f-7f3906ea0128/1/CengageOpenNow_CollegeSuccessNarrative.pdf . Project : Open Now: College Success. License : CC BY: Attribution
- Image of someone writing on paper. Authored by : Free-Photos. Provided by : Pixabay. Located at : pixabay.com/photos/writing-pen-man-ink-paper-pencils-1149962/. License : Other . License Terms : pixabay.com/service/terms/#license


12.14: Adjectives and Adverbs
Adjectives and adverbs are descriptive words that bring your writing to life.
Adjectives and Adverbs
An adjective is a word that describes a noun or a pronoun. It often answers questions such as which one , what kind , or how many?
1. The green sweater belongs to Iris.
2. She looks beautiful .
- In sentence 1, the adjective green describes the noun sweater .
- In sentence 2, the adjective beautiful describes the pronoun she .
An adverb is a word that describes a verb, an adjective, or another adverb. Adverbs frequently end in -ly . They answer questions such as how , to what extent , why , when , and where .
3. Bertrand sings
horribly
.
4. My sociology instructor is
extremely
wise.
5. He threw the ball very accurately.
- In sentence 3, horribly describes the verb sings . How does Bertrand sing? He sings horribly .
- In sentence 4, extremely describes the adjective wise . How wise is the instructor? Extremely wise.
- In sentence 5, very describes the adverb accurately . How accurately did he throw the ball? Very accurately.
Exercise 1
Complete the following sentences by adding an adjective or adverb. Identify the word as an adjective or an adverb (Adj, Adv).
- Frederick ________ choked on the piece of chicken when he saw Margaret walk through the door.
- His ________ eyes looked at everyone and everything as if they were specimens in a biology lab.
- Despite her pessimistic views on life, Lauren believes that most people have ________ hearts.
- Although Stefan took the criticism ________, he remained calm.
- The child developed a ________ imagination because he read a lot of books.
- Madeleine spoke ________ while she was visiting her grandmother in the hospital.
- Hector’s most ________ possession was his father’s bass guitar from the 1970s.
- My definition of a ________ afternoon is walking to the park on a beautiful day, spreading out my blanket, and losing myself in a good book.
- She ________ eyed her new coworker and wondered if he was single.
- At the party, Denise ________ devoured two pieces of pepperoni pizza and a several slices of ripe watermelon.
Comparative versus Superlative
Comparative adjectives and adverbs are used to compare two people or things.
1. Jorge is thin .
2. Steven is thinner than Jorge.
- Sentence 1 describes Jorge with the adjective thin . It is not a comparative.
- Sentence 2 compares Jorge to Steven, stating that Steven is thinner . So thinner is the comparative form of thin .
Form comparatives in one of the following two ways:
- If the adjective or adverb is a one syllable word, add -er to it to form the comparative. For example, big , fast , and short would become bigger , faster , and shorter in the comparative form.
- If the adjective or adverb is a word of two or more syllables, place the word more in front of it to form the comparative. For example, happily , comfortable , and jealous would become more happily , more comfortable , and more jealous in the comparative.
Superlative adjectives and adverbs are used to compare more than two people or two things.
1. Jackie is the loudest cheerleader on the squad.
2. Kenyatta was voted the most confident student by her graduating class.
- Sentence 1 shows that Jackie is not just louder than one other person, but she is the loudest of all the cheerleaders on the squad.
- Sentence 2 shows that Kenyatta was voted the most confident student of all the students in her class.
Form superlatives in one of the following two ways:
- If the adjective or adverb is a one-syllable word, add -est to form the superlative. For example, big , fast , and short would become biggest , fastest , and shortest in the superlative form.
- If the adjective or adverb is a word of two or more syllables, place the word most in front of it. For example, happily , comfortable , and jealous would become most happily , most comfortable , and most jealous in the superlative form.
Tip
Remember the following exception: If the word has two syllables and ends in - y, change the - y to an - i and add - est . For example, happy would change to happiest in the superlative form; healthy would change to healthiest .
Exercise 2
Edit the following paragraph by correcting the errors in comparative and superlative adjectives.
Our argument started on the most sunny afternoon that I have ever experienced. Max and I were sitting on my front stoop when I started it. I told him that my dog, Jacko, was more smart than his dog, Merlin. I could not help myself. Merlin never came when he was called, and he chased his tail and barked at rocks. I told Max that Merlin was the most dumbest dog on the block. I guess I was angrier about a bad grade that I received, so I decided to pick on poor little Merlin. Even though Max insulted Jacko, too, I felt I had been more mean. The next day I apologized to Max and brought Merlin some of Jacko’s treats. When Merlin placed his paw on my knee and licked my hand, I was the most sorry person on the block.
Exercise 3
Complete the following sentences by selecting the correct comparative or superlative adjective or adverb. Then copy the completed sentence onto your own sheet of paper .
a. Denise has a (cheerful) ________ outlook on life than her husband.
b. I don’t mean to brag, but I think I am the (good) ________ cook in my family.
c. Lydia is the (thoughtful) ________ person I know.
d. Italy experienced the (bad) ________ heat wave in its history last year.
e. My teacher, Ms. Beckett, is the (strange) ________ person I know, and I like that.
f. Dorian’s drawing skills are (good) ________ this semester than last.
g. My handwriting is the (sloppy) ________ of all my classmates.
h. Melvin’s soccer team played (badly) ________ than it did last season.
i. Josie’s pen writes (smooth) ________ than mine.
j. I felt (lucky) ________ than my sister because I got in to the college of my choice.
Irregular Words: Good , Well , Bad , and Badly
Good , well , bad , and badly are often used incorrectly. Study the following chart to learn the correct usage of these words and their comparative and superlative forms.
Table 12.14 -- Comparatives and Superlatives
| Comparative | Superlative | ||
|---|---|---|---|
| Adjective | good | better | best |
| Adverb | well | better | best |
| Adjective | bad | worse | worst |
| Adverb | badly | worse | worst |
Good versus Well
Good is always an adjective—that is, a word that describes a noun or a pronoun. The second sentence is correct because well is an adverb that tells how something is done.
Incorrect: Cecilia felt that she had never done so good on a test.
Correct: Cecilia felt that she had never done so well on a test.
Well is always an adverb that describes a verb, adverb, or adjective. The second sentence is correct because good is an adjective that describes the noun score .
Incorrect: Cecilia’s team received a well score.
Correct: Cecilia’s team received a good score.
Bad versus Badly
Bad is always an adjective. The second sentence is correct because badly is an adverb that tells how the speaker did on the test.
Incorrect: I did bad on my accounting test because I didn’t study.
Correct: I did badly on my accounting test because I didn’t study.
Badly is always an adverb. The second sentence is correct because bad is an adjective that describes the noun thunderstorm .
Incorrect: The coming thunderstorm looked badly .
Correct: The coming thunderstorm looked bad .
Better and Worse
The following are examples of the use of better and worse :
- Tyra likes sprinting better than long distance running.
- The traffic is worse in Chicago than in Atlanta.
Best and Worst
The following are examples of the use of best and worst :
- Tyra sprints best of all the other competitors.
- Peter finished worst of all the runners in the race.
Tip
Remember better and worse compare two persons or things. Best and worst compare three or more persons or things.
Exercise 4
Write good, well, bad, or badly to complete each sentence. Copy the completed sentence onto your own sheet of paper.
- Donna always felt ________ if she did not see the sun in the morning.
- The school board president gave a ________ speech for once.
- Although my dog, Comet, is mischievous, he always behaves ________ at the dog park.
- I thought my back injury was ________ at first, but it turned out to be minor.
- Steve was shaking ________ from the extreme cold.
- Apple crisp is a very ________ dessert that can be made using whole grains instead of white flour.
- The meeting with my son’s math teacher went very ________.
- Juan has a ________ appetite, especially when it comes to dessert.
- Magritte thought the guests had a ________ time at the party because most people left early.
- She ________ wanted to win the writing contest prize, which included a trip to New York.
Exercise 5
Write the correct comparative or superlative form of the word in parentheses. Copy the completed sentence onto your own sheet of paper.
- This research paper is ________ (good) than my last one.
- Tanaya likes country music ________ (well) of all.
- My motorcycle rides ________ (bad) than it did last summer.
- That is the ________ (bad) joke my father ever told.
- The hockey team played ________ (badly) than it did last season.
- Tracey plays guitar ________ (well) than she plays the piano.
- It will go down as one of the ________ (bad) movies I have ever seen.
- The deforestation in the Amazon is ________ (bad) than it was last year.
- Movie ticket sales are ________ (good) this year than last.
- My husband says mystery novels are the ________ (good) types of books.
Writing at Work \(\PageIndex{1}\)
The irregular words good , well , bad , and badly are often misused along with their comparative and superlative forms better , best , worse , and worst . You may not hear the difference between worse and worst , and therefore type it incorrectly. In a formal or business-like tone, use each of these words to write eight separate sentences. Assume these sentences will be seen and judged by your current or future employer.
Contributors and Attributions
CC LICENSED CONTENT, SHARED PREVIOUSLY:
- Adapted from Writing for Success . Provided by: The Saylor Foundation. License: CC-NC-SA 3.0 .
- Adapted from College ESL Writers: Applied Grammar and Composing Strategies for Success . A uthored by: Barbara Hall and Elizabeth Wallace. P rovided by: GALILEO Open Learning Materials. L icense: CC BY-NC-SA (3.0): Attribution
ALL RIGHTS RESERVED CONTENT:
- Adjectives and Adverbs . Authored by: American English. License: All Rights Reserved. License Terms: Standard YouTube License.
This page most recently updated on June 8, 2020.


1.5: Common Terms Related to Aging
The following terms are related to the study of aging. You should be come comfortable with meaning of each of these terms as they will be used throughout the text and class discussions.
- Aging is the process of growing old, regardless of chronological age.
- Senescence is a term used to describe the group of deleterious effects that lead to a decrease in the efficient functioning of an organism with increasing age and to an increased probability of death.
- Senility refers to the physical and mental deterioration often associated with old age.
- Elderly describes a person who is 60 to 75 years of age, as defined by the World Health Organization.
- Old describes a person who is 76 to 90 years of age, as defined by the World Health Organization.
- Very old describes a person who is over 90 years of age, as defined by the World Health Organization.
- Gerontology is the scientific study of the process of aging.
- Geriatrics refers to health care delivery for the elderly. It is the branch of medicine that treats the conditions and diseases associated with aging and old age.
-
Longevity
refers to the duration of life of an individual.
- Mean longevity is the average longevity of a population. This often referred to as life expectancy.
- Maximum longevity is the age at death of the longest-lived member of the population.
- Demography is the statistical study of human populations collectively, including geographic changes and trends in births, marriages, diseases, and deaths.
Contributors and Attributions
CC licensed content, Original
- Common Terms Related to Aging. Authored by : Kelly, Jessica. Provided by : Herkimer College. Located at : NA. Project : AtD Course. License : CC BY: Attribution


5.10: Skills Checklist- Full Bed Bath
- Gather Supplies: Basin, warm water, soap, shampoo and conditioner if used, lotion, six washcloths, two towels, barrier, gloves, clean clothes or gown, and linen bag or hamper
-
Routine Pre-Procedure Steps:
- Knock on the client’s door.
- Perform hand hygiene.
- Introduce yourself and identify the resident.
- Maintain respectful, courteous, and professional communication at all times.
- Provide for privacy.
- Explain the procedure to the client.
-
Procedure Steps:
- Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
- Place a towel under one leg, keeping the rest of the body covered with the bath blanket.
- Wash the leg with soap, only exposing the leg.
- Wash the feet with soap.
- Rinse the leg and feet.
- Pat the leg and feet dry.
- Repeat on the other leg.
- Raise the side rail on one side of the bed.
- Move to the opposite side of the bed and assist the resident to roll on their side using a lift sheet or other supportive device.
- Wash the back while keeping the rest of the body covered.
- Rinse the back.
- Pat the back dry.
- Dispose of the gown and used linens into the linen bag or laundry hamper.
- Ask the resident if they would like lotion. If applying lotion, wear gloves.
- Perform perineal care using clean linens according to Chapters 5.18 & 5.19 “Perineal Care Skills Checklists.”
- Assist the resident to put on a clean gown or clothes and apply an incontinence product if needed.
- While wearing gloves, empty the equipment.
- Rinse the equipment.
- Dry the basin.
- Return the equipment to storage.
- Dispose of soiled linen in the designated laundry hamper.
- Remove the gloves, turning them inside out.
-
Post-Procedure Steps:
- Perform hand hygiene.
- Check for resident comfort and if anything else is needed.
- Be sure the bed is low and locked. Check the brakes.
- Place the call light or signaling device within reach of the resident.
- Open the door and privacy curtain.
- Perform hand hygiene.
- Document and report any skin issues or changes noted with the resident.
Note: Shampooing can be done before washing face, after washing back, or after perineal care per resident preference. See “ Shampoo Skills Checklist ” for specific steps.
View a YouTube video [1] of an instructor demonstrating a f ull bed bath:
- Chippewa Valley Technical College. (2022, December 3). Full Bed Bath . [Video]. YouTube. Video licensed under CC BY 4.0 . https://youtu.be/j5GYMOvjjtk ↵


4.3: Health in America
By the end of this section, you should be able to:
- Identify public health priorities in the United States.
- Discuss the leading causes of death in the United States.
- Describe trends in mortality due to the most common infectious and chronic diseases across populations.
- Discuss health trends in the United States.
- Compare health outcomes in the United States with those of high-income or “peer” countries.
- Describe the nurse’s role in addressing health inequities.
The United States has the highest health care spending compared to peer countries, such as Germany and France, but with worse health outcomes (Gunja et al., 2023; Hoyert, 2023). Infant and maternal mortality rates are higher than those of peer countries, and the life expectancy of Americans is lower. As first introduced in What Is Population Health?, Healthy People is an initiative of the U.S. Department of Health and Human Services (HHS) to improve the health and well-being of all people in the United States. The Healthy People initiative began in 1980 with the launch of Healthy People 1990 (ODPHP, 2021b). Every 10 years, HHS releases updated national health objectives to shape health promotion and disease prevention efforts in the United States for the next decade. Healthy People 2030 is the most current version.
Healthy People 2030
The vision of Healthy People 2030 is a society in which everyone can reach their full potential for health and well-being across their lifespan. Healthy People 2030’s mission is to support the nation’s efforts to improve the population’s health and well-being. Several foundational principles support Healthy People’s mission (ODPHP, 2021a). These principles use a holistic perspective of health and recognize the importance of equitable access to health care and health promotion. Working to achieve this vision is a shared responsibility among all individuals, groups, and organizations and is essential to creating a thriving, equitable society. Creating healthy physical, social, and economic environments and effective policy is essential for achieving the vision of Healthy People 2030. Health Disparities discusses the impact of health disparities and SDOH on care outcomes in more detail.
This video describes the Healthy People 2030 framework.
Watch the video, and then respond to the following questions.
- Which of the focus areas is new to the Healthy People initiatives?
- How did the definition of health literacy change?
- Do you think this video is effective in explaining the fundamental concepts of Healthy People 2030 to the lay public? Why or why not?
While the vision, mission, and foundational principles provide a framework essential for the utility of Healthy People 2030, the goals and objectives shape how the country’s health experts work to identify priorities and implement targeted interventions. The overall goals of Healthy People include promoting health and well-being throughout the lifespan by creating supportive environments and public policy.
To measure the nation’s progress toward the Healthy People 2030 vision, HHS has identified Overall Health and Well-Being Measures (OHMs). The OHMs are used to assess the Healthy People 2030 vision over its 10-year span to determine the overall health and well-being of the U.S. population and see where improvements have occurred. Because they are broad goals, OHMs do not have targets and are not classified as objectives (ODPHP, n.d.-e). The OHMs are subdivided into three tiers, as shown in Table 4.2.
| Tiers | OHMs |
|---|---|
| Well-being | OHM-01: Overall well-being (expressed as overall life satisfaction, reflecting the cumulative contributions of health and non-health factors) |
| Healthy life expectancy |
OHM-02: Life expectancy at birth—free of activity limitation
OHM-03: Life expectancy at birth—free of disability OHM-04: Life expectancy at birth— in good or better health |
| Summary mortality and health |
OHM-05: Life expectancy at birth
OHM-06: Free of activity limitation OHM-07: Free of disability OHM-08: Respondent-assessed health status—in good or better health |
The next layer of the Healthy People framework includes the core, developmental, and research objectives. Within the core objectives, Healthy People 2030 identifies high-priority health issues and challenges, which are referred to as leading health indicators (LHIs). LHIs are objectives that cover the lifespan and allow for the assessment and promotion of health at the community, state, and national levels (ODPHP, n.d.-d). LHIs address high-priority issues that have a significant effect on health outcomes. The indicators must address the SDOH; health disparities , which are preventable differences of health among populations; and health equity , or the expectation that everyone has a fair opportunity to attain their highest level of health. LHIs are modifiable, meaning they can be improved by implementing evidence-based interventions and strategies. The LHIs were developed to focus resources on the major causes of death and disease, aiming to improve health (ODPHP, n.d.-c).
An example of an intervention for the LHI of children and adolescents with obesity was a study conducted by a school nurse to promote healthy choices. The relevant Healthy People 2030 objective is to “reduce the proportion of children and adolescents with obesity” (ODPHP, n.d.-h), and students in this study earned points toward a special healthy class snack for each healthy choice they made. The study resulted in a 25 percent decrease in the consumption of chocolate milk, demonstrating the positive effect that a health promotion intervention can have on an LHI (Lovell, 2018). Each LHI represents an opportunity to develop health promotion activities that address the modifiable risk factors leading to death and disease. Figure 4.3 illustrates the relationship between the OHMs, objectives, and LHIs.
Leading Causes of Death in the United States
According to the National Center for Health Statistics (2023b), the following were the 10 leading causes of death in the United States in 2021:
- Heart disease
- Cancer
- COVID-19
- Accidents (unintentional injuries)
- Stroke (cerebrovascular diseases)
- Chronic lower respiratory diseases
- Alzheimer’s disease
- Diabetes
- Chronic liver disease and cirrhosis
- Nephritis, nephrotic syndrome, and nephrosis
Tracking shifts in mortality trends serves as a guide for developing public health policies and interventions. In 2020, for example, the prevalence of COVID-19 and COVID-19-related deaths led the United States to declare a national state of emergency. State governments implemented policies such as travel restrictions, school closures, physical distancing, and mask wearing based on COVID-19 case rates. Although initially delayed, testing for COVID-19 infection was implemented to obtain surveillance data that was then used to prevent transmission, ultimately leading to decreased mortality rates (Unruh et al., 2022; CDC, 2023a).
Population health nurses must be familiar with disease trends. The following section briefly reviews the leading causes of death in the United States.
Heart Disease
Heart disease has been the leading cause of death globally for more than 20 years and is the most common cause of death in the United States for both men and women overall, as well as for most racial and ethnic groups (CDC, 2023d; World Heart Federation, 2023). The key risk factors for developing this condition include high blood pressure and high blood cholesterol. Several modifiable risk factors, such as smoking, obesity, and physical inactivity, contribute to the development of heart disease, and public health efforts are in place to create awareness (CDC, 2023d). For example, the American Heart Association (AHA) sponsors the Go Red for Women Health Movement to create awareness about heart disease in women.
Cancer
Although deaths from cancer have decreased over the past 30 years, it remains the second leading cause of death in the United States. Lung cancer is the most prevalent cause of cancer death, followed by colorectal, pancreatic, breast, and prostate cancer. Public health campaigns to increase awareness of cancer risk factors, such as smoking, as well as advances in screening and treatment, have contributed to the decrease in cancer deaths (American Cancer Society, 2022; CDC, 2022b). The CDC supports initiatives such as the National Breast and Cervical Cancer Early Detection Program ( NBCCEDP ) to reduce cancer deaths (CDC, 2022b).
Accidents
Accidents or unintentional injuries were the third leading cause of death in the United States in 2022 (Ahmad et al., 2023). The CDC (2022a) identifies unintentional injuries such as unintentional poisoning (including opioid and other drug overdoses), drowning, motor vehicle accidents, and falls as the leading cause of death for Americans aged 1 to 44 years old. Interventions to prevent death from these types of injuries are included in the Healthy People 2030 objectives. For example, as drug overdoses are the leading cause of unintentional deaths, Healthy People 2030 supports interventions such as the distribution of naloxone and providing medication for addiction treatment, and HHS has a prevention strategy for preventing overdoses (ODPHP, n.d.-c;).
COVID-19
As indicated previously, after the start of the pandemic, COVID-19 quickly became a leading cause of death, with the weekly death toll peaking in the week of January 9, 2021, at more than 25,000 deaths per week (CDC, 2023a). However, COVID-19-related deaths have since dropped, and according to the CDC’s provisional mortality data for 2022, it was the fourth leading cause of death that year (Ahmad et al., 2023). It is unclear at this time if COVID-19 will remain a leading cause of death.
The COVID-19 pandemic has strained global health systems and the health care workforce. Even before the pandemic, there was a long-standing health care worker shortage, and the WHO currently predicts a global shortfall of 18 million health care workers by the year 2030, although more recent data indicate these numbers may be improving (WHO, 2022d). The WHO groups its member states into six regions for purposes of data analysis and reporting (GreenFacts, 2023). The health care workforce shortage is of high concern in the African region, which consists of 46 countries, because it bears almost one-quarter (24 percent) of the world’s disease burden but has only 3 percent of the world’s health care workers (WHO, 2022d).
Stroke
Stroke is the fifth leading cause of death in the United States. Deaths from stroke have increased from 2018 and are more likely to occur among low-income populations, certain racial and ethnic groups, and populations in certain parts of the country. The risk of stroke can be decreased by controlling high blood pressure and treating high cholesterol levels. Teaching people to recognize symptoms is key to helping more people get the treatment they need in a stroke emergency (ODPHP, n.d.-g).
Chronic Lower Respiratory Disease
Emphysema, chronic bronchitis, and nonreversible asthma belong to a group of illnesses known as chronic obstructive pulmonary disease, or COPD. The symptoms of COPD make it hard to breathe and can cause death. COPD is a major cause of disability and one of the leading causes of death in the United States. Unfortunately, many people who have COPD may not know it. Healthy People 2030 has a goal to reduce emergency department visits for COPD by reducing smoking and exposure to air pollution , teaching people with COPD how to manage it, and promoting early detection (ODPHP, n.d.-f).
Alzheimer’s Disease
Alzheimer’s disease is a type of dementia characterized by cognitive decline. Growing research suggests ways to help prevent or delay dementia instead of merely treating it and reducing its impact. Although no cure is presently available to eliminate Alzheimer’s disease, early recognition and early intervention may slow its deteriorating progress (ODPHP, n.d.-d).
Diabetes
Adults who are diagnosed with diabetes are at an increased risk of early death. Complications such as heart disease and kidney disease are among the leading causes of death in people with diabetes. Improving diabetes treatments may reduce the risk for these complications and lower the death rate for people with diabetes (ODPHP, n.d.-b).
Chronic Liver Disease, Cirrhosis, and Nonalcoholic Fatty Liver Disease
In the United States, chronic liver disease and cirrhosis are among the leading causes of death. Notably, death rates have been consistently higher for Black Americans. Most cirrhosis deaths are due to alcohol use. Other risk factors include type 2 diabetes, injecting drugs using shared needles, and exposure to others’ blood and body fluids (American Liver Foundation, 2022). Effective policies to reduce cirrhosis deaths include taxing and regulating alcohol sales and restricting alcohol advertising. According to the WHO (2023g), alcohol taxation and price regulation are among the most effective strategies to decrease alcohol-related harm.
Nonalcoholic fatty liver disease (NAFLD) develops when excess fat builds up in the liver for reasons unrelated to alcohol use. This is one of the most common causes of liver disease and is associated with obesity and type 2 diabetes. NAFLD increases a person’s risk of cardiovascular disease, type 2 diabetes, and metabolic syndrome (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], n.d.).
Nephritis, Nephrotic Syndrome, and Nephrosis
Nephritis and nephrotic syndrome/nephrosis are forms of kidney disease and a leading cause of death in the United States. Nephritis is an inflammatory condition, frequently resulting from infection, that can lead to renal failure if untreated. Nephrosis or nephrotic syndrome is a group of symptoms that reflect poor renal function caused by renal diseases or other causes, such as diabetes or hepatitis. The symptoms include proteinuria, hypoalbuminemia, peripheral edema, and hyperlipidemia (NIDDK, n.d.). Chronic kidney disease affects more than one in seven adults, and many do not realize they have it (NIDDK, 2023). Additionally, these conditions disproportionately affect low-income and racial and ethnic minority groups (ODPHP, n.d.-a; Norris, 2021).
Trends in Mortality
Over the past 100 years in the United States, life expectancy has increased and rates of death have decreased. Figure 4.4 depicts the death and life expectancy rates for the United States from 1900 to 2018 (National Center for Health Statistics, 2022).
An unprecedented decline in mortality occurred during the 20th century in the United States, and life expectancy rose by more than 30 years during this time frame. Infectious diseases were the leading cause of mortality in the early 1900s. Urbanization and the resulting increased population density provided a prime opportunity for diseases such as tuberculosis and influenza to spread. Improvements in sanitation and nutrition, coupled with the development of antibiotics, led to a sharp decline in deaths from infectious diseases. As the death rate from infectious diseases decreased, chronic illnesses emerged as the primary cause of mortality. Smoking, for example, was identified as a leading cause of cardiovascular disease and cancer. Public health campaigns successfully developed awareness of smoking risks, resulting in decreased chronic diseases attributed to tobacco use (The Wharton School, 2016).
Following decades of increases, life expectancy in the United States is now falling (National Center for Health Statistics, 2022). One factor alone is not responsible for this drop, and there are also disparities in mortality rates among population groups within the United States. The next section will explore trends in mortality as a starting point to develop an understanding of this concerning change (Shmerling, 2022).
Mortality Trends in Infectious Disease
Infectious disease remains a public health threat in the United States despite its decline as a leading cause of mortality. COVID-19, as previously discussed, is still a leading cause of death in the United States. Americans of all ages are at risk for mortality from other infectious diseases, such as bacterial sepsis in newborns or influenza and pneumonia for people from 1 year of age through late adulthood. Vaccines, such as those for COVID-19 and influenza, significantly reduce the risk of these infectious diseases and their complications (CDC, 2021b).
Mortality Trends in Chronic Disease
Chronic disease is a condition that is present for more than 1 year and requires ongoing medical intervention and/or limits activities of daily living. According to the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP, 2022c), 6 out of 10 Americans have one chronic disease, and 4 in 10 have two or more. The major chronic diseases in the United States include heart disease and stroke, diabetes, and cancer. These diseases are the leading causes of death and disability in the United States and share the same risk factors, which include:
- tobacco use,
- exposure to secondhand smoke,
- poor nutrition,
- physical inactivity, and
- excessive alcohol use.
Chronic diseases account for most health care costs in the United States, and interventions to prevent them have significant economic and health benefits for Americans (NCCDPHP, 2022a). Because it is estimated that by 2050, most Americans aged 50 years and above across all races will have one or more chronic conditions, it is imperative that health promotion efforts address this concerning trend (Ansah & Chiu, 2022).
Mortality Trends in Suicide and Drug Overdose
Suicide is a major public health concern in the United States. As defined by the National Institutes of Health, suicide is death caused by self-directed injurious behavior with intent to die as a result of the behavior. Suicide rates increased by 37 percent between the years 2000 and 2018 and then decreased by 5 percent between 2018 and 2020. Unfortunately, rates nearly returned to their peak in 2021 (National Institute of Mental Health, 2023). Suicide is a leading cause of death for Americans aged 10 to 34. High suicide rates correlate to certain demographic factors, such as Native American ethnicity, and certain occupations, such as military service. Research suggests that increased suicide rates correlate to increases in mood and affective disorders and are associated with alcohol and drug use (Martinez-Ales at al., 2020).
Drug overdose s can be intentional or unintentional. The United States is currently experiencing an opioid overdose epidemic. There were more than six times the number of fatal drug overdoses in 2021 compared to 1999. The epidemic involves three waves or types of deaths. The initial wave started with prescription opioids in the 1990s, followed by increases in heroin-related deaths in 2010, and the third wave began in 2013 with synthetic opioids such as illegally manufactured fentanyl (CDC, 2023g). For more information on drug overdoses, refer to Caring for Populations and Communities in Crisis.
Trends in Maternal-Newborn Mortality
In the United States, maternal mortality is measured in three different ways. Pregnancy-associated deaths are those that occur during pregnancy or within a year after the end of pregnancy, regardless of the cause of death. Pregnancy - related deaths occur either during pregnancy or within one year after the end of pregnancy from a pregnancy-related complication; days 43 to 365 postpartum are considered “late” maternal deaths. Finally, maternal mortality refers to deaths that occur while pregnant or within 42 days after the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, not including accidental or incidental causes. Nurses should understand these distinctions because many pregnancy-related deaths in the United States occur during the postpartum period (Tikkanen et al., 2020).
The maternal mortality rate in the United States exceeds that of other high-income countries and is increasing (Douthard et al., 2021). This trend is concerning, as the mortality rate of peer countries is decreasing, and more than 8 out of 10 maternal deaths are preventable. The maternal mortality rate is exceptionally high for Black Americans (Trost et al., 2022). Adverse maternal outcomes are often related to a combination of factors, such as an increased prevalence of chronic conditions, barriers to health care, or pregnant clients’ distrust of the health care system. Pregnant clients also experience variations in the quality of care they receive throughout the pregnancy, which is related to geographical location and socioeconomic status (Collier & Molina, 2019).
Infant mortality refers to an infant’s death before their first birthday, and the rate in the United States also exceeds that of peer countries (Petrullo, 2023). Infants born to Black people in the United States are at higher risk for mortality than those born to White people (Office of Minority Health, 2022). A primary cause of infant mortality is maternal pregnancy complications. Social and economic inequities drive maternal and infant mortality disparities in the United States. Initiatives at the federal, state, and community levels are striving to address the maternal and infant health crisis in America. Preventing pregnancy complications and maternal death is also a Healthy People 2030 goal (Hill et al., 2022).
Health Care Disparities
Various factors are responsible for the health disparities, or preventable differences in attaining health, among population groups in the United States.  Health care disparities can originate from health inequities, which are avoidable differences in the health of groups and communities (National Academies of Sciences, Engineering, and Medicine, 2017; Ndugga & Artiga, 2023). Barriers such as a lack of insurance or transportation and cultural differences between clients and providers affect health care quality. All Americans deserve an opportunity to attain their highest health level, which will only occur if disparities are addressed and health equity is achieved (CDC, 2022e). Health Disparities covers this topic in greater detail.
In a recent review of U.S. deaths from 2000 to 2019, National Center for Health Statistics researchers determined that non-Hispanic American Indians or Alaska Natives (AIAN) and non-Hispanic Black Americans experienced higher mortality rates than White, Asian, and Latina/Latino Americans. These findings highlight the pervasive nature of health disparities that urgently need to be addressed.
(See GBD U.S. Health Disparities Collaborators, 2023.)
Health Trends in the United States
There are several notable positive health trends in the United States. Deaths attributed to heart disease, despite it being the leading cause of death, are on the decline. The age-adjusted heart disease death rate decreased from 182.8 per 100,000 in 2009 to 161.5 per 100,000 in 2019 (CDC, 2023d). Other trends include the following (National Center for Health Statistics, 2023a):
- The percentage of children with asthma declined from 9.6 percent in 2009 to 7.0 percent in 2019.
- Cigarette smoking among adults declined from 20.6 percent in 2009 to 14.2 percent in 2019.
- In 2019, 12.0 percent of Americans under age 65 were uninsured, which is down from 17.5 percent in 2009.
- In 2019, 8.5 percent of people delayed or did not receive medical care due to cost in the past 12 months, compared with 11.4 percent in 2009.
Healthy People 2030 data suggest that several goals and objectives for specific leading health indicators have improved or are improving. For example, more adults use information technology to track health care data or communicate with providers. The number of toxic pollutants released into the environment has improved, and the overall cancer death rate is improving (ODPHP, n.d.-d).
Not all trends are positive. For example, rural Americans are at greater risk for poor health outcomes and face more disparities than their urban counterparts. In 2019, the death rate for people living in rural areas was 20 percent higher than for those living in urban areas (Curtin & Spencer, 2021). A higher incidence of poverty, less access to health care, and longer distances to health care services negatively affect this demographic’s health status. Modifiable risk factors, such as smoking, limited leisure-time physical activity, and lack of seat belt use, also contribute to poor health outcomes for rural Americans. The rates of the 10 leading causes of death in the United States were also higher in 2019 in rural areas than in urban areas (Curtin & Spencer, 2021). Rural health promotion initiatives are indicated to improve the health of those living in rural areas (CDC, 2023c; Curtin & Spencer, 2021). In addition, suicide rates have increased in almost every state over the last two decades (ODPHP, n.d.-i).
Visit the Institute for Health Metrics and Evaluation’s U.S. Health Map , an interactive map showing life expectancy and cause-specific mortality by race and ethnicity. Select a community of interest to view life expectancy or mortality rates at the county level, and then respond to the following questions.
- How does the county you selected compare to surrounding counties?
- Are the statistics consistent with what you expected? Why or why not?
- How might a public health or community health nurse use this tool?
Comparison Between United States and Other High-Income Countries
The United States spends more on health care and medical technologies than other high-income countries and outperforms them on preventive measures, such as flu vaccines and cancer screenings. However, the United States has poor health outcomes and the lowest life expectancy compared to peer countries. Contributing factors include a low supply of physicians, a high incidence of chronic diseases, and obesity rates that are twice the average of peer countries (Tikkanen & Abrams, 2020). The data obtained from comparing the performance of the U.S. health care system against peer countries can be used to address areas in need of improvement. Improving access to health care, including availability and affordability, is a key factor in improving health outcomes (Tikkanen & Abrams, 2020). To find out more about how the United States compares to other countries, visit this Health System Tracker from the Peterson Center on Healthcare and KFF.
This video examines why the United States spends so much money on health care but ranks lower in overall efficiency than other, similar countries.
Watch the video, and then respond to the following questions.
- Name three factors that drive health care costs in the United States.
- Why is health care less expensive in other countries?
- Why does the patient-as-a-consumer model not work in health care, according to the video? Do you agree or disagree?
The Nurse’s Role in Addressing Health Inequities
Nurses have a professional and moral responsibility to address the inequities that are embedded in the U.S. health care system. Access to health care is a key component of equitable care, and nurses are uniquely qualified to assist Americans in navigating the health care system. Nurses in all health care settings play an essential role in identifying and addressing barriers to care by providing person-centered care. This model addresses the physical, mental, and social needs of clients, families, and caregivers. Nurses in population health can work as case managers and connect their clients with appropriate resources to meet their health-related needs. Nurses can match community resources with learning opportunities, reduce health disparities, and assist in processing the outcomes of community-based interventions (Arisoto et al., 2018).
In addition to working directly with groups of clients, nurses must advocate for policies that improve access to care for all Americans (Oruche & Zapolski, 2020). There are several ways nurses can become more involved in the policymaking process, including:
- joining a professional nurses association or other politically active health care organization which can provide an opportunity to learn more about and participate in the policymaking process;
- building relationships with elected officials to raise their awareness of health-related issues; and
- educating clients on how they can become politically active and affect positive health-related policy changes.
The nurse’s role in population health extends to many areas of health. The leading health indicators identified by Healthy People 2030 serve as a good starting point for addressing priority issues. For example, a nurse can work with Head Start programs, school systems, and day care centers to bring mobile dental hygiene care to students. A school nurse can advocate for and implement changes regarding the content of school vending machines and healthier menus for school breakfast and lunch options. The nurse may address drug overdose deaths by educating the community on the use of Narcan or expanding access to methadone clinics. The nurse can work with state and local governments on plans to address pollution issues by planting more trees or address traffic issues to minimize exhaust fumes associated with car idling. See Advocating for Population Health for more information on how nurses may participate in advocacy efforts.


6.1: Background Material
Force and Motion Sensors
The equipment used in this lab includes two sensing devices that take data in real time. One of these is a force sensor (located on one end of the cart), which measures force exerted in Newtons, and the other a motion sensor (activated by the turning of the wheels of the cart), which measures velocity in meters per second.
Both of these sensors send their readings via Bluetooth to a laptop at regular intervals. Upon receiving this information, the computer plots the values versus time on graphs, the details of which we will use for our analysis. Forces are recorded as positive values when they push on the sensor, and negative values when they pull on it. Motion detected by the motion sensors is recorded as a positive value when the object is moving in the direction where the force sensor is in front.
The experiment involves collisions of nearly-frictionless rolling carts. As we are interested in the forces exerted on each cart as a function of time, we don't want the collision to be between two hard surfaces, or the period of time over which the forces act will be too brief to measure, even at the impressive sampling rate of our force sensors. We have therefore engineered the two types of collisions we will study so that the force of the collision occurs at a "leisurely" pace.
For simplicity, all of the cases we will study will involve a stationary target cart, but the conclusions of the experiment will be independent of this choice.
Figure 6.1.1 – Anatomy of the Collisions
We therefore will end up with four graphs plotted at the same time – a force and velocity for each cart. The information we extract from these plots will allow us to draw conclusions about impulse, momentum conservation, and kinetic energy conservation.


7.1: Introduction and Historical Contextto today
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Music, like the other arts, does not occur in a vacuum. Changes brought on by advances in science, and inventions resulting from these advances, affected composers, artists, dancers, poets, writers, and many others at the turn of the twentieth century. Inventions from the late Romantic era had a great impact on economic and social life in the twentieth century. These inventions included the light bulb, the telephone, the automobile, and the phonograph. Thomas Edison invented the phonograph in 1877 and patented it in 1878. While researching means to improve the telegraph and telephone, Edison developed a way to record sound on tinfoil-coated cylinders. He would speak into a mouthpiece and the recording needle would indent a groove into the cylinder. The playing needle would then follow the groove, and the audio could be heard through a horn speaker (in the shape of a large cone). Edison improved his invention and formed the Edison Speaking Phonograph Company to market the invention. Edison’s phonograph had an especially great influence on the spread of music to larger audiences; he also advertised the device’s usefulness for dictation and letter writing, recording books for the blind, recording and archiving family members’ voices, music boxes, toys, and clocks that verbally announce the time with prerecorded voices. In 1917, such audio phonograph devices were purchased by the U.S. Army for $60 each and used to make troops feel closer to home during World War I. Listen to this rare audio clip of Edison expressing his thanks to the troops for their service and sacrifice: www. americaslibrary.gov/assets/aa/edison/aa_edison_phonograph_3.wav
What defines twentieth-century music? Clearly, the twentieth century was a time of great upheaval in general, including in music. The sense of rapid change and innovation in music and art of this period is a reflection of the dramatic changes taking place in the world at large. On a political level, the twentieth century was one of the bloodiest and most turbulent periods in history. While wars are a constant throughout all of human history, the global nature of twentieth-century politics resulted in conflicts on a scale never before seen; World War II alone is widely regarded as the deadliest conflict in human history in terms of total deaths, partly due to advancements in technology such as machine guns, tanks, and eventually the atom bomb.
It’s no surprise that music of this period mirrored the urgency and turmoil in the world at large. For many composers, the raw emotion and sentimentality reflected in the music of the nineteenth century had grown tiresome, and so they began an attempt to push the musical language into new areas. Sometimes, this meant bending long-established musical rules to their very limits, and, in some cases, breaking them altogether. One of the by-products of this urgency was fragmentation. As composers rushed to find new ways of expressing themselves, different musical camps emerged, each with their own unique musical philosophies. We now categorize these musical approaches with fancy terms ending in “-ism,” such as “primitivism,” “minimalism,” “impressionism,” etc. We will discuss many of these individual movements and techniques as well as address what makes them unique, but before we do this, let’s first talk about those things that most (but not all) music of the twentieth century has in common.
7.3.1 Melody
One of the ways in which composers deviated from the music of the nineteenth century was the way in which they constructed melodies. Gone were the singable, sweeping tunes of the Romantic era. In their place rose melodies with angular shapes, wide leaps, and unusual phrase structures. In some cases, melody lost its status as the most prominent feature of music altogether, with pieces that featured texture or rhythm above all else.
7.3.2 Harmony
The most obvious difference between twentieth-century music and what pre- ceded it is the level of harmonic dissonance. This is not a new phenomenon. The entire history of Western music can be viewed in terms of a slowly increasing acceptance of dissonance, from the hollow intervals of the Middle Ages all the way to the lush chords of the nineteenth century. However, in the twentieth century the use of dissonance took off like a rocket ship. Some composers continued to push the tolerance level for dissonance in the context of standard tonal harmony. One example is through the use of polytonality , a technique in which two tonal centers are played at the same time. Some composers sought to wash their hands of the rules of the past and invented new systems of musical organization. Often, this resulted in music that lacked a tonal center, music that we now refer to as atonal . Some com- posers such as Igor Stravinsky even tried their hand at more than one style.
7.3.3 Rhythm
In preceding centuries, music was typically relegated to logical, symmetrical phrases that fell squarely into strict meters. That all changed at the dawn of the twentieth century. Igor Stravinsky’s Rite of Spring famously undermined the au- dience’s expectation of the role of rhythm by abandoning strict meter for rapidly changing time signatures. Instead of the steady familiar time signatures containing three or four beats, Stravinsky peppered in measures containing an odd number of beats such as five or seven. This created a sense of unease in the audience by removing something from the music that they had previously taken for granted: a steady and unwavering sense of meter. In America, the rhythmic innovations of ragtime and jazz influenced both Western art music and popular music from that time on. Especially important was the use of syncopation, which was addressed in the first chapter.
7.3.4 Texture and Timbre
As memorable melodies and traditional harmonies began to break down, some composers looked to new tonal colors through the use of new instruments such as synthesizers , instruments that electronically generate a wide variety of sounds. In other cases, traditional instruments were used in nontraditional ways. For example, John Cage famously composed piano pieces that called for objects such as coins and tacks to be placed on the strings to create unique effects.
7.3.5 The Role of Music
Music has had many roles throughout history. The music of Josquin helped enhance worship. The works of Haydn and Mozart reflected the leisurely life of the aristocracy. Opera served as a form of musical escapism in the daring and ambitious works of composers such as Wagner. In the twentieth century, music began to move away from entertainment into the realm of high art. Composers sought to challenge the listener to experience music in new ways and in some cases to reevaluate their fundamental notions of what music is. This sense of revolution was not limited to music; it was also taking place throughout the art world. As we discuss the many “-isms” in music, we will see direct parallels with the visual arts.
7.3.6 Compositional Styles: The “-isms”
Near the beginning of the twentieth century, numerous composers began to rebel against the excessive emotionalism of the later Romantic composers. Two different styles emerged: the Impressionist style led by Claude Debussy and Maurice Ravel, and the atonal Expressionist style led by Arnold Schoenburg. Both styles attempted to move away from the tonal harmonies, scales, and melodies of the previous period. The impressionists chose to use new chords, scales, and colors while the expressionists developed a math-based twelve-tone system that attempted to completely destroy tonality.
7.3.7 Impressionism
The two major composers associated with the Impressionist movement are Claude Debussy and Maurice Ravel. Both French-born composers were searching for ways to break free from the rules of tonality that had evolved over the previous centuries. Impressionism in music, as in art, focused on the creator’s impression of an object, concept, or event. The painting labeled Image 7.1, by the French impressionist painter Claude Monet, suggests a church or cathedral, but it is not a clear portrait. It comprises a series of paint daubs that suggest something that we may have seen but that is slightly out of focus.
In the painting labeled Image 7.2, we see how Monet distilled a scene into its most basic elements. The attention to detail of previous centuries is abandoned in favor of broad brushstrokes that are meant to capture the momentary “impression” of the scene. To Monet, the objects in the scene, such as the trees and boats, are less important than the interplay between light and water. To further emphasize this interplay, Monet pares the color palate of the painting down to draw the focus to the sunlight and the water.
Similarly, Impressionist music does not attempt to follow a “program” like some Romantic compositions. It seeks, rather, to suggest an emotion or series of emotions or perceptions.
Listen to the example of Debussy’s La Mer (The Sea) linked below. Pay particular attention to the way the music seems to rise and fall like the waves in the sea and appears to progress without ever repeating a section. Music that is written this way is said to be “ through-composed .” The majority of impressionist music is written in this manner. Even though such music refrains from following a specific program or story line, La Mer as music suggests a progression of events through- out the course of a day at sea. Note that Debussy retained the large orchestra first developed by Beethoven and used extensively by Romantic composers. This music, unlike the Expressionism we will visit next, is tonal and still uses more traditional scales and chords.
debussy , La Mer https://www.youtube.com/watch?v=hlR9rDJMEiQ
Impressionist composers also liked using sounds and rhythms that were unfamiliar to most Western European musicians. One of the most famous compositions by Maurice Ravel is entitled Bolero . A Bolero is a Spanish dance in three-quarter time, and it provided Ravel with a vehicle through which he could introduce different (and exotic, or different sounding) scales and rhythms into the European orchestral mainstream. This composition is also unique in that it was one of the first to use a relatively new family of instruments at the time: the saxophone family. Notice how the underlying rhythmic pattern repeats throughout the entire composition, and how the piece gradually builds in dynamic intensity to the end.
maurice ravel, Bolero https://www.youtube.com/watch?v=A2BYkJS8GE0
Unlike composers such as Bach, Ravel was not born into a family of musicians. His father was an engineer, but one who encouraged Ravel’s musical talents. After attending the Paris Conservatory as a young man, Ravel drove a munitions truck during World War I. Throughout all this time, he composed compositions of such lushness and creativity that he became one of the most admired composers in France, along with Claude Debussy. His best known works are the aforementioned Bolero, Concerto in D for Piano, La valse, and an orchestral work entitled Daphnes et Chloe.
Daphnis et Chloé was originally conceived as a ballet in one act and three scenes and was loosely based on a Greek drama by the poet Longus. The plot on which the piece is based concerns a love affair between the title characters Daphnis and Chloe. The first two scenes of the ballet depict the abduction and escape of Chloe from a group of pirates. However, it is the third scene that has become so immortalized in the minds of music lovers ever since. “Lever du jour,” or “Day- break,” takes place in a sacred grove and depicts the slow build of daybreak from the quiet sounds of a brook to the birdcalls in the distance. As dawn turns to day, a beautiful melody builds to a soaring climax, depicting the awakening of Daphnis and his reunion with Chloe.
After the ballet’s premier in June of 1912, the music was reorganized into two suites, the second of which features the music of “Daybreak.” Listen to the record- ing below and try to imagine the pastel colors of daybreak slowly giving way to the bright light of day.
|
Listening Guide For audio, go to: |
| Composer: Maurice Ravel |
| Composition: Daphnis and Chloe, Suite No. 2: “Lever du jour” |
| Date: 1913 |
| Genre: Orchestral Suite |
| Form: Through-composed |
| Performing Forces: orchestra/chorus |
| Timing | Performing Forces, Melody, and Texture |
|
0:00 |
Murmuring figures depicting a brook.
|
| 0:52 | Sweeping melody reaches first climax, and then dies down slowly. Strings over murmuring accompaniment. |
| 1:09 | Strings and clarinet enter with song-like melody. Melody over murmuring strings. |
| 1:30 |
Flute enters with dance-like melody. Melody over murmuring strings |
| 1:48 | Clarinet states a contrasting melody. Melody over murmuring strings. |
| 2:13 |
Chorus enters while strings continue melody. Melody over murmuring strings and “Ah” of chorus. |
| 2:53 |
Melody rises to a climax and then slowly diminishes. Full Orchestra and Chorus. |
| 3:13 |
Sweeping melody enters in strings to a new climactic moment. Full Orchestra. |
| 3:19 |
Motif starts in low strings and then rises through the orchestra. Full Orchestra. |
| 4:05 |
Chorus enters for a final climactic moment, then slowly dies away. Full Orchestra and Chorus. |
| 4:34 |
Oboe enters with repeating melody. |
| 4:58 |
Clarinet takes over repeating melody and the piece slows to a stop.
|


4.8: Resistance to Popular Culture
Although popular culture has been expanding rapidly at the expense of folk culture, it is not without resistance. Although it is not strictly-speaking true, global culture is perceived as largely corporate, secular, and western. Each of these aspects have their own critics.
Anti-globalists fall into two main groups. The first are leftists who oppose the power that has accumulated to corporations and the authoritarian state. The other group are rightists who prefer that power be centered at the state level, and who fear that globalization naturally undermines state sovereignty.
In some places, globalization is the same thing as modernization is the same thing as westernization which is perceived as secular (or even atheistic), materialistic and corrupt. Movements such as Al-Qaeda or Islamic State are violently opposed to popular culture, although they would not have a problem if their idea of the ideal culture were to become fully global. Rejecting modern popular culture often also involves elevating a nostalgic, often imaginary golden age as the only acceptable model of society.
Many people feel that symbols and representations of popular culture are erasing the very personality of regional cultures. Resistance to popular culture can come in many forms. Let us revisit the concept of fundamental needs, which are universal, and how they vary geographically. Locally sourced food products, customs, and recipes are pitted against global fast-food giants that provide inexpensive and easy access to ready-made food products. There has been an uprising of farm-to-table businesses, the Slow Food movement, and an emphasis on fair-trade products.


14.4: Adding New Assessments
Once an assignment is created, instructors need to add assessments before students can use ADAPT. There are three approaches to address this: (1) adding via the Assignment Remixer, (2) adding via Meta-tag searches, and (3) direct adding via page ID codes.
Adapt Assignment Remixer
The Assignment Remixer is modeled after the OER Remixer on the LibreTexts libraries to faciliate easy drag and drop of assessments in an existing assignment.
- Open the Assignment.
- Click “Add Assessment”
- Open “Assignment Remixer” Tab
- You can filter courses by School, Instructor's name, course name or all three
- Select the assignment
- Move questions from the left side of the screen to the right to add them to your assignment.
- You can preview any question by clicking on its name.
- Click “Add all questions” if you want to add all listed questions
- You can delete chosen questions by clicking on the Recycle Bin icon next to it
- You don’t have to save your selection. Once you leave this page, all of the questions that you’ve selected will be added to your assignment.
Adding Assessments by Tag
An alternative way to add assessments to an assignment is to search for meta-information on the question, e.g., subject, author, key words, learning objectives etc. Build and aligning to tagging frameworks is still underway, so this feature has limited utility at this time.
You can add assessments from the Query Database using tags. To do that:
- Open the Assignment.
- Click "Add Assessments"
- Open "Search Query by Tag" tab
- Start typing the tag (you can use any word related to the questions you are looking for - topic, concept, etc.).
- Select the right tag from the drop-down list and click "Get Questions". The tag will be added to "Chosen Tags" section on the right. You can delete the tag by clicking on the recycle bin icon next to it
- All questions that are currently in the Query that have that tag assigned to them will be shown below. You can go through all of them by clicking at the numbers and select the questions that you want. To add an assessment click “Add Question”. If the question was added successfully you will see a confirmation message
Adding Assessments by Page ID
The LibreTexts library editor and infrastructure is used as the primary mechanism to create, curate, and add problems to the ADAPT library. This is a straightforward procedure once a problem has been created on a LibreTexts library as a dedicated page. Each LibreTexts page has a ID# at the top (once logged in with an instructor account). This is the procedure to add an assessment on a new LibreTexts page into your assignment.
- Open the Assignment.
- Click "Add Assessments"
- Open "Direct import by page ID" tab
- Navigate to the page in LibreText library (Query or any other Library) and copy the page ID (numbers only)
- Navigate back to Adapt page.
- Choose Default Library (the library where the question is located) from drop-down menu and type/paste the page ID in the field on the right
- Click "Import Questions". If the import was successful you will see a confirmation.
Note: you can add more than one question from the same library using page ID's. To do that, type/paste page ID's separated with comas and click "Import Questions".


8.8: Types of Jails
Callstack:
at (Bookshelves/Corrections/Introduction_to_the_American_Criminal_Justice_System_(Burke_et_al.)/08:_Corrections/8.08:_Types_of_Jails), /content/body/p[1]/@function, line 1, column 1
Older generation jails are jails that are typically linear in design, with cell doors separating rooms or sections down long corridors. Many jails operate with this design. Newer generation jails are more podular in design, where multiple cells face a central area. Additionally, when these podular designs are used, a direct supervision approach is also often used. Direct supervision is where there are no particular barriers between the deputies and the detainees within a facility. For example, the image below depicts what a direct supervision jail may look like.
New Generation Jail Design
Older Generation Jail Design
-
Minton, T. D. (2012). Jail inmates at midyear, statistical tables.
U.S. Department of Justice.
https://www.bjs.gov/content/pub/pdf/jim11st.pdf
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