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Context: Given that the composition of hospice patients’ terminal diagnoses has become increasingly diverse, understanding whether hospices provide quality care to patients, regardless of disease, is important. However, data comparing diagnosis and caregiver-reported outcomes remain scarce. Objectives: To analyze the association between the composition of patients’ terminal diagnoses and caregiver-reported quality measures. Methods: Using cross-sectional, publicly available data from the Centers for Medicare & Medicare Services (CMS), we analyzed data collected from 2015–2019. We conducted general linear model analyses to identify associations between hospice characteristics/practices and caregiver-reported outcomes. Results: Of the 2810 hospices, those that cared for a greater percentage of dementia patients had fewer caregivers, on average, who rated hospice a 9 or 10 (where 0 = low, 10 = high; β = −.094; 95% CI = −.147, −.038), reported they always received help for pain and symptoms (β = −.106, CI = −.156, −.056), and reported definitely having received the training they needed (β = −.151, CI = −.207, −.095). Those caring for more stroke patients had fewer caregivers, on average, who rated hospice a 9 or 10 (β = −.184, CI = .252, −.115), reported they always received help for pain and symptoms (β = −.188, CI = −.251, −.126), reported definitely having received the training they needed (β = −.254, CI = −.324, −.184), and reported that the hospice offered the right amount of emotional/spiritual support (β = −.056, CI = −.093, −.019). Conclusion: Hospices that cared for a greater proportion of dementia and stroke patients had poorer scores on caregiver-reported quality measures. These findings support efforts to identify mechanisms underlying these differences and to design strategies to ensure optimal outcomes for hospice patients regardless of diagnosis.

This randomized controlled trial examines the effects of a school garden intervention on children's fruit and vegetable (FV) consumption at school over two years. We randomly assigned schools to the intervention group that received gardens and related curriculum (n = 24) or to the waitlist control group that received gardens and curriculum at the conclusion of the study (n = 22). Children in second, fourth, and fifth grade at baseline (n = 2767) in low-income schools (n = 46) in four U.S. States (Arkansas, Iowa, New York, and Washington) participated. The intervention comprised gardens for each classroom; a curriculum focused on nutrition, plant science, and horticulture, including activities and FV tasting sessions; resources for the school that addressed topics such as soil contamination and food safety; an implementation guide focused on issues related to planning, planting, and maintaining the garden through the year, engaging volunteers, summer gardening, building community capacity, and sustaining the gardening program. FV consumption was measured by photographing lunches before and after children ate, for 2-3 days, at baseline and at each of 3 subsequent periods of data collection during the intervention. FV consumption was calculated using Digital Food Image Analysis. Among children in the intervention, fruit consumption and low-fat vegetable consumption increased from pre-garden baseline to post-garden more than among control group children. Garden intervention fidelity (GIF) also predicted changes in dietary intake, with more robust interventions showing a stronger effect than weaker interventions. GIF-lessons was a particularly potent predictor of change in dietary intake. School gardens modestly increase children's FV consumption at school.

Objective In this cross-sectional study of 237 older adults, we ascertained the importance of seven pain treatment goals and identified factors associated with their perceived importance. Methods Participants (mean age = 72 years) ranked each goal (e.g., pain reduction; finding a cure) on a 1 (not at all important) to 10 (extremely important) scale. We used general linear models to identify sociodemographic and pain factors independently associated with the perceived importance of each goal and repeated measures mixed models to examine their relative importance. Results The goal with the lowest adjusted score was “minimize harmful side effects from pain medications” with a mean (standard error [SE]) of 6.75 (0.239), while the highest ranked goals, “finding a cure,” and “reducing my pain” had mean scores of 8.06 (0.237) and 7.89 (0.235), respectively. Pain reduction did not differ significantly from the average of the other 6 goals (P = .072) but was significantly different when compared with the goals of minimizing side effects (P Conclusions Future research is needed to establish the benefits of eliciting treatment goals when delivering pain care to older adults.

BACKGROUND While there are many interventions to support caregivers, text messaging has the capability to be an adjunct to clinical practice on a wide-spread basis. The Department of Veterans Affairs Annie text messaging system was developed to assist Veterans with self-care. OBJECTIVE This paper reports on the first system-wide implementation of a text messaging protocol for caregivers in a national health care system with an Annie stress management protocol for caregivers of Veterans. METHODS After pilot testing, in late 2019, a year-long protocol for caregivers with three messages a week focusing on education, motivation/inspiration, and activities to alleviate stress was begun. An online evaluation occurs at six months. RESULTS As of September 2021, 3807 caregivers had participated in the stress protocol. Caregivers report that the messages have been useful in increasing their confidence, managing their stress, and helping them take care of themselves and their loved one. This success has led to bereavement, taking care of you, COVID-19 precautions and symptoms, and dementia behaviors protocols, with a total of 5643 caregivers enrolled as of September 2021. CONCLUSIONS Caregivers frequently feel overlooked by the health care system but caregivers report that the messages make them feel cared for and less lonely. Text messaging, incorporated into clinical settings and health care systems, represents a seamless, low-cost way to provide useful and meaningful support to caregivers.

Context Given the high prevalence of burdensome symptoms in palliative care (PC) and increasing use of complementary and integrative medicine (CIM) therapies, research is needed to determine how often and what types of CIM therapies providers recommend to manage symptoms in PC. Objective To document recommendation rates of CIM for target symptoms and assess if CIM use varies by provider characteristics. Methods Nationwide survey of physicians (MD and DO), physician assistants, and nurse practitioners in PC. Results Participants (N=404) were mostly female (71.3%), physicians (74.9%), and cared for adults (90.4%). Providers recommended CIM an average of 6.82 times per-month (95% CI: 6.04-7.60) and used an average of 5.13 (95% CI: 4.90-5.36) out of 10 CIM modalities. Respondents recommended mind-body medicines (e.g., meditation, biofeedback) most, followed by massage, and acupuncture/acupressure. The most targeted symptoms included pain; followed by anxiety, mood disturbance and distress. Recommendation frequencies for specific modality-for-symptom combinations ranged from little use (e.g., aromatherapy for constipation) to occasional use (e.g., mind-body interventions for psychiatric symptoms). Finally, recommendation rates increased as a function of pediatric practice, non-inpatient practice setting, provider age, and proportion of effort spent delivering palliative care. Conclusion To the best of our knowledge, this is the first national survey to characterize PC providers’ CIM recommendation behaviors and assess specific therapies and common target symptoms. Providers recommended a broad range of CIM but do so less frequently than patients report using CIM. These findings should be of interest to any provider caring for patients with serious illness.

Adolescents’ opportunities to benefit from the life wisdom of older persons are very limited. To address this issue, we designed and tested the Building a Community Legacy Together (BCLT) program based on research on the benefits of older people’s wisdom for youth development. In the intervention, the youth participants were trained prior to conducting interviews with older persons regarding their advice for living. The youth participants analyzed the information obtained and presented a summary report to the community. The participants were 93 middle and high school youth who were randomly assigned to the treatment condition with the BCLT program (n = 47) or to the control condition (n = 46). The outcome measures included sense of purpose, self-esteem, attitudes toward older people, confidence interacting with older people, and interest in working with older people. Quantitative and qualitative data were also collected regarding the subjective assessments of the program’s success. We found significant positive effects for the BCLT participants regarding their sense of purpose in life, attitudes toward older people, comfort interacting with older people, and interest in working with older people. The subjective assessments of the participants were overwhelmingly positive. The findings indicate that BCLT had positive effects for the youth participants and support the further development and testing of wisdom-sharing intergenerational programs.

Partial migration is a common life-history strategy among ungulates living in seasonal environments. The decision to migrate or remain on a seasonal range may be influenced strongly by access to high-quality habitat. We evaluated the influence of access to winter habitat of high quality on the probability of a female white-tailed deer (Odocoileus virginianus) migrating to a separate summer range and the effects of this decision on survival. We hypothesized that deer with home ranges of low quality in winter would have a high probability of migrating, and that survival of an individual in winter would be influenced by the quality of their home range in winter. We radiocollared 67 female white-tailed deer in 2012 and 2013 in eastern Washington, United States. We estimated home range size in winter using a kernel density estimator; we assumed the size of the home range was inversely proportional to its quality and the proportion of crop land within the home range was proportional to its quality. Odds of migrating from winter ranges increased by 3.1 per unit increase in home range size and decreased by 0.29 per unit increase in the proportion of crop land within a home range. Annual survival rate for migrants was 0.85 (SD = 0.05) and 0.84 (SD = 0.09) for residents. Our finding that an individual with a low-quality home range in winter is likely to migrate to a separate summer range accords with the hypothesis that competition for a limited amount of home ranges of high quality should result in residents having home ranges of higher quality than migrants in populations experiencing density dependence. We hypothesize that density-dependent competition for high-quality home ranges in winter may play a leading role in the selection of migration strategy by female white-tailed deer.

Background. Research has found a strong link between ageism, in the form of negative stereotypes, prejudice, and discrimination toward older people, and risks to their physical and mental health. Little is known, however, about the effectiveness of strategies to reduce ageism. Objectives. To assess the relative effects of 3 intervention types designed to reduce ageism among youths and adults—education, intergenerational contact, and combined education and intergenerational contact—by conducting a systematic review and meta-analysis. Search Methods. We searched PubMed, PsycINFO, AgeLine, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Index Medicus, Database of Abstracts of Reviews of Effects (DARE), Epistemonikos, Cochrane Database of Systematic Reviews, Campbell Collaboration, PROSPERO, GreyLit, and OpenGrey. We identified additional records by hand-searching reference lists of relevant review articles as well as records included in the meta-analysis. Two independent reviewers completed the search and screening process. Selection Criteria. Eligible studies were those that (1) evaluated an intervention designed to reduce ageism, (2) examined at least 1 ageism outcome in relation to older adults, (3) used a design with a comparison group (randomized or nonrandomized), and (4) were published after 1970, when the ageism concept was developed. Data Collection and Analysis. Two independent reviewers extracted study-level data from records using a common data collection spreadsheet. They also assessed study quality by using the Cochrane Risk of Bias Tool, and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool to assess quality of outcome evidence. Primary outcomes were attitudes toward older people and accuracy of knowledge about aging and older people. Secondary outcomes included comfort with older adults, anxiety about one’s own aging, and interest in working in the field of geriatrics or gerontology. We carried out meta-analyses with statistical mixed models. Main Results. We identified 63 eligible studies (1976–2018) with a total sample of 6124 participants. Ageism interventions demonstrated a strongly significant effect on attitudes (differences of standardized mean differences [dD] = 0.33; P D = 0.42; P D = 0.50; P D = 0.13; P = .33) or working with older adults (dD = −0.09; P = .40). Combined interventions with education and intergenerational contact showed the largest effects on attitudes. We found stronger effects for females and for adolescent and young adult groups. Authors’ Conclusions. Interventions are associated with substantial reduction in ageism and should be part of an international strategy to improve perceptions of older people and the aging process. Additional research using more rigorous designs to examine the effects of interventions is strongly recommended. Public Health Implications. Ageism has well-established negative effects on the physical and mental health of older people. Findings suggest that relatively low-cost, feasible strategies involving education and intergenerational contact can serve as the basis of effective interventions to reduce ageism.

We have recently commissioned a novel infrared (0:9-1:7 μm) integral field spectrograph (IFS) called the Wide Integral Field Infrared Spectrograph (WIFIS). WIFIS is a unique instrument that offers a very large field-of-view (5000 x 2000) on the 2.3-meter Bok telescope at Kitt Peak, USA for seeing-limited observations at moderate spectral resolving power. The measured spatial sampling scale is ~ 1 x 1" and its spectral resolving power is R ~ 2; 500 and 3; 000 in the z J (0:9 - 1:35 μm) and Hshort (1:5 - 1:7 μm) modes, respectively. WIFIS's corresponding etendue is larger than existing near-infrared (NIR) IFSes, which are mostly designed to work with adaptive optics systems and therefore have very narrow fields. For this reason, this instrument is specifically suited for studying very extended objects in the near-infrared such as supernovae remnants, galactic star forming regions, and nearby galaxies, which are not easily accessible by other NIR IFSes. This enables scientific programs that were not originally possible, such as detailed surveys of a large number of nearby galaxies or a full accounting of nucleosynthetic yields of Milky Way supernova remnants. WIFIS is also designed to be easily adaptable to be used with larger telescopes. In this paper, we report on the overall performance characteristics of the instrument, which were measured during our commissioning runs in the second half of 2017. We present measurements of spectral resolving power, image quality, instrumental background, and overall efficiency and sensitivity of WIFIS and compare them with our design expectations. Finally, we present a few example observations that demonstrate WIFIS's full capability to carry out infrared imaging spectroscopy of extended objects, which is enabled by our custom data reduction pipeline.

To examine preliminarily the effectiveness of a short message service (SMS) text message-based social support intervention for reducing daily pain and pain interference levels, improving affect and perceptions of social support in patients with chronic noncancer pain, and exploring the feasibility of a novel mobile application to track perceptions of pain and pain interference.Participants (17 men, 51 women) from 2 pain clinics in New York City downloaded a pain tracking application (App) on their Smartphone and used it to record twice-daily pain, pain interference, and affect scores over the 4-week study period. Participants were randomly assigned to receive standard care (control) or standard care along with receipt of twice-daily supportive SMS text messages delivered during the second and third week of the study (intervention). Demographic and clinical data were obtained at baseline, and social support measures were administered at baseline and at 4 weeks. Statistical analysis was carried out using general linear mixed models, taking into account variances associated with time of assessments and with patients.The social support intervention reduced perceptions of pain and pain interference and improved positive affect for chronic noncancer pain patients assigned to the intervention condition in comparison with controls. Participants completed approximately 80% of the daily measurements requested.These findings establish the feasibility of collecting daily pain data using a mobile tracking App and provide significant implications and insight into a nuanced approach to reducing the daily experience of pain through mobile technology, especially because of its accessibility.

Purpose: This article reports the results of a randomized,controlledevaluationofPartnersinCaregivingin a Special Care Environment, an intervention designed to improve communication and cooperation between staffandfamiliesofresidentsinnursinghomedementia programs. Design and Methods: Participants included 388 family members and 384 nursing staff members recruited from 20 nursing homes, randomly assigned to treatment and control conditions. Project staff conducted training sessions on communication and conflict-resolution techniques with two groups at the intervention sites: staff and residents’ family members, followed by a joint meeting with facility administrators. Results: Families, staff, residents, and facility programs in the intervention facilities all demonstrated positive outcomes from program participation. Families experienced significant improvement in communicating with staff and in staff behaviors toward them, and spouses of residents increased their care involvement. Staff reported reduced conflict with families and reduced depression; burnout for nurses increased for individuals in the control group but not those in the treatment group. Behavioral symptoms decreased for residents, and facilities implemented more family-focused programs. Implications: Effective staff and family partnerships are critical in caring forresidentswithdementia.ThePartnersinCaregiving inaSpecialCareEnvironmentprogramisanevidencebased intervention that enables these partnerships to develop and thrive, translating into improved experiences for residents, families, and staff.

The current study examined whether the Nurse Family Partnership (NFP), an intervention in which mothers received home visitation by registered nurses pre- and postnatally, reduced mothers' vulnerability to the effects of stressful life events several years after the program was completed. Data from a randomized trial of the NFP were examined for mothers (N = 324) who were generally low-income, young, and unmarried at the time of the birth of their first child. Structured interviews were done with mothers about 15 years after the program began. Results showed that experiencing uncontrollable stressful life events, such as the death of a loved one, led to fewer negative outcomes (fewer mental health problems, less binge drinking, and better parenting practices) among nurse-visited mothers than among mothers receiving no visitation. Furthermore, the program's effect on reducing vulnerability to the negative impact of life events was particularly evident among parents who were younger or had a lower sense of personal control at intake. These findings suggest that, in addition to preventing the occurrence of negative outcomes that were direct targets of the intervention, the NFP more generally enhanced mothers' ability to cope with future stressful life events.

This study investigated the relationship between child maltreatment and the early onset of problem behaviors in the Elmira Nurse Home Visitation Program. Participants were predominantly low-income and unmarried mothers and their first-born children who were randomized either to receive over 2 years of home-visitation services by nurses or to be placed in a comparison group. Data were drawn from a follow-up study that took place when the children were 15 years of age. Results demonstrated that, in the comparison group, child maltreatment was associated with significant increases in the number of early onset problem behaviors reported by the youth. For the youth in the nurse-visited group there was no relationship between maltreatment and early onset problem behaviors. We suggest that this finding was due to the effects of the intervention in reducing the number as well as the developmental timing of the maltreatment incidents. Results suggest that prenatal and infancy home visiting by nurses can moderate the risk of child maltreatment as a predictor of conduct problems and antisocial behavior among children and youth born into at-risk families.

We discuss properties of the atmospheric water vapor above the high Andean plateau region known as the Llano de Chajnantor, in the Atacama Desert of northern Chile. A combination of radiometric and radiosonde measurements indicate that the median column of precipitable water vapor (PWV) above the plateau at an elevation of 5000 m is approximately 1.2 mm. The exponential scaleheight of the water vapor density in the median Chajnantor atmosphere is 1.13 km; the median PWV is 0.5 mm above an elevation of 5750 m. Both of these numbers appear to be lower at night. Annual, diurnal and other dependences of PWV and its scaleheight are discussed, as well as the occurrence of temperature inversion layers below the elevation of peaks surrounding the plateau. We estimate the background for infrared observations and sensitivities for broad band and high resolution spectroscopy. The results suggest that exceptional atmospheric conditions are present in the region, yielding high infrared transparency and high sensitivity for future ground-based infrared telescopes., 25 pages, 11 figures, to appear in the PASP (July 2001)

Two randomized trials of prenatal and infancy home visitation conducted in semirural and urban areas are described and their results presented. The studies provide consistent findings that nurse home visitors can improve women's health related behaviors, qualities of infant caregiving, and can help women improve their own life-course development (reflected in behaviors such as rates of subsequent pregnancies and births, and receipt of welfare). The effects of the program on reducing the rates of dysfunctional care (reflected in rates of child maltreatment and health care encounters for injuries) were concentrated in women with few psychological resources. Reviews of other randomized trials indicate that to produce comparable effects, interventions must include those program ingredients embodied in the model tested in these two trials. © 1998 John Wiley & Sons, Inc.

Objective. To analyze the influence of a comprehensive program of nurse home visitation on the intellectual functioning of children born to women who smoked cigarettes during pregnancy. Design. Randomized clinical trial. Treatment 1: sensory and developmental screening at ages 1 and 2 years; treatment 2: screening plus free transportation for prenatal and well-child care; treatment 3: screening, transportation, plus prenatal home visitation; treatment 4: screening, transportation, prenatal home visitation, plus postnatal home visitation through the children's second birthdays. Setting. Semirural community in Upstate New York. Participants. 400 families in which the mothers registered before the 30th week of pregnancy and had no previous live births. Eighty-five percent of the mothers were either teenagers, unmarried, or poor. Analysis was limited to whites, who constituted 89% of sample. Intervention. Nurse home visitation during pregnancy (treatments 3 and 4) or during pregnancy and the first 2 years of the child's life (treatment 4). During pregnancy, the nurses helped women improve their health-related behaviors, informal social support, and linkage with needed community services. Main findings. Children born to women who smoked 10 or more cigarettes per day at registration during pregnancy and who were assigned to treatments 3 and 4 had IQs (averaging across the 3rd and 4th years of life) that were 4.86 (95% CI: 0.47, 9.26) points higher after adjustment for covariates than did children born to women who smoked 10+ cigarettes per day and who were assigned to treatments 1 and 2. The positive influence of the home-visiting program on reducing the harmful effect of smoking appears to be due to prenatal visitation. Conclusion. Comprehensive prenatal home-visitation services can offset the impairment in intellectual functioning associated with substantial maternal smoking during pregnancy.

A completed series of reports on a randomized trial (N = 400) indicated that, in contrast to comparison services, prenatal and infancy nurse home visitation improved a wide range of maternal and child health outcomes among poor, unmarried, and teenaged women bearing first children in a semirural county in upstate New York. Eighty-nine percent of the sample was white, and all analyses focused on this group. In this article, an analysis of the net cost of the home-visitation program from the perspective of government spending is presented. The average per-family cost of the program in 1980 dollars was $3,246 for the sample as a whole, and $3,133 for low-income families. Treatment differences in government expenditures for Aid to Families with Dependent Children, Food Stamps, Medicaid, and Child Protective Services, minus tax revenues due to maternal employment (also expressed in 1980 dollars), were conceived as government savings. By the time the children were 4 years of age, government savings were $1,772 (95% confidence interval [CI]: -$557, $4,102) for the sample as a whole, and $3,498 (95% CI: $569, $6,427) for low-income families. Within 2 years after the program ended, after discounting, the net cost of the program (program costs minus savings) for the sample as a whole was $1,582 per family. For low-income families, the cost of the program was recovered with a dividend of $180 per family.

To describe characteristics of older adults who received opioids for chronic non-cancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes.Retrospective cohort study.Primary care practice in New York City.Eligible patients wereor=65 and newly started on an opioid for CP.Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than 1 year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events.Participants (N = 133) had a mean age of 82 (range = 65-105), were mostly female (84%), and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range = 0-1,880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment foror=1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events.Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.

This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80-7/1/09) with a mean study population age of 60 and older. Forty-three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60-73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain-producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5-156 weeks), and only five (12%) lasted longer than 12 weeks. In meta-analyses, effect sizes were -0.557 (P.001) for pain reduction, -0.432 (P.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36-item Health Survey was 0.191 (P=.17) for the physical component score and -0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short-term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long-term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.

The TEDI (TripleSpec - Exoplanet Discovery Instrument) will be the first instrument fielded specifically for finding low-mass stellar companions. The instrument is a near infra-red interferometric spectrometer used as a radial velocimeter. TEDI joins Externally Dispersed Interferometery (EDI) with an efficient, medium-resolution, near IR (0.9 - 2.4 micron) echelle spectrometer, TripleSpec, at the Palomar 200" telescope. We describe the instrument and its radial velocimetry demonstration program to observe cool stars., 6 Pages, To Appear in SPIE Volume 6693, Techniques and Instrumentation for Detection of Exoplanets III

OBJECTIVE. Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS. We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women RESULTS. Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS. By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.

This study evaluated the anti-inflammatory medication regimens in children with persistent asthma, determined their health care utilization patterns, and evaluated factors associated with failure to seek and/or receive appropriate treatment. Parents of 68% of children who qualified for anti-inflammatory medications by National Asthma Education and Prevention Program (NAEPP) guidelines reported their use. However, only 14% received an optimal regimen (mild intermittent symptoms), while 55% were still symptomatic despite reported medications (suboptimal regimen). Nearly half of symptomatic children did not have a health care visit; of those who did, 61% had no corrective action documented. Factors contributing to variations in regimen and utilization are discussed.

Purpose: This article reports on a randomized, controlled study of Partners in Caregiving, an intervention designed to increase cooperation and effective communication between family members and nursing home staff. Design and Methods: Participants included 932 relatives and 655 staff members recruited from 20 nursing homes, randomly assigned to treatment and control conditions. Parallel training sessions on communication and conflict resolution techniques were conducted with the family and staff in the treatment group, followed by a joint meeting with facility administrators. Results: Positive outcomes were found for both family and staff members in the treatment group. Both groups showed improved attitudes toward each other, families of residents with dementia reported less conflict with staff, and staff reported a lower likelihood of quitting. Implications: Multiple studies report significant interpersonal stress between family members of nursing home residents and facility staff members. Partners in Caregiving appears to be an effective way to improve family‐ staff relationships in nursing homes.

background Despite dramatic declines in children’s blood lead concentrations and a lowering of the Centers for Disease Control and Prevention’s level of concern to 10 µg per deciliter (0.483 µmol per liter), little is known about children’s neurobehavioral functioning at lead concentrations below this level. methods We measured blood lead concentrations in 172 children at 6, 12, 18, 24, 36, 48, and 60 months of age and administered the Stanford–Binet Intelligence Scale at the ages of 3 and 5 years. The relation between IQ and blood lead concentration was estimated with the use of linear and nonlinear mixed models, with adjustment for maternal IQ, quality of the home environment, and other potential confounders. results The blood lead concentration was inversely and significantly associated with IQ. In the linear model, each increase of 10 µg per deciliter in the lifetime average blood lead concentration was associated with a 4.6-point decrease in IQ (P=0.004), whereas for the subsample of 101 children whose maximal lead concentrations remained below 10 µg per deciliter, the change in IQ associated with a given change in lead concentration was greater. When estimated in a nonlinear model with the full sample, IQ declined by 7.4 points as lifetime average blood lead concentrations increased from 1 to 10 µg per deciliter. conclusions Blood lead concentrations, even those below 10 µg per deciliter, are inversely associated with children’s IQ scores at three and five years of age, and associated declines in IQ are greater at these concentrations than at higher concentrations. These findings suggest that more U.S. children may be adversely affected by environmental lead than previously estimated.

Objective. To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when delivered by nurses.Methods. A randomized, controlled trial was conducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight consecutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hundred thirty-five women were randomized to control, paraprofessional, or nurse conditions.Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children’s second birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children’s second birthdays.The main outcomes consisted of changes in women’s urine cotinine over the course of pregnancy; women’s use of ancillary services during pregnancy; subsequent pregnancies and births, educational achievement, workforce participation, and use of welfare; mother-infant responsive interaction; families’ home environments; infants’ emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stimuli; and children’s language and mental development, temperament, and behavioral problems.Results. Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant paraprofessional effects.In contrast to their control-group counterparts, nurse-visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/mL); by the study child’s second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months).Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control-group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psychological resources were less likely to exhibit low emotional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological resources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women’s use of ancillary prenatal services, educational achievement, use of welfare, or their children’s temperament or behavior problems.For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses.Conclusions. When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical significance for some outcomes is probably attributable to limited statistical power to detect small effects. Nurses produced significant effects on a wide range of maternal and child outcomes.

Background Accurate symptom evaluation is a critical component of asthma management. Limited data are available about the accuracy of symptom evaluation by children with asthma and their parents, or the impact of various symptom-monitoring strategies on asthma morbidity outcomes. Objective The purpose of this randomized clinical trial was to evaluate the effect of three different intensities of symptom monitoring on asthma morbidity outcomes. Methods One hundred sixty-eight children (ages 6 to 19) of diverse racial, geographic, and socioeconomic backgrounds were randomized to 1 of 3 treatment groups (subjective symptom evaluation, symptom-time peak expiratory flow rate (PEFR) monitoring, daily PEFR monitoring) in this longitudinal, clinical trial. Outcome measures included a summary asthma severity score, forced expiratory volume in 1 second, symptom days, and health care utilization. Results Children who used PEFR meters (PFMs) when symptomatic had a lower asthma severity score, fewer symptom days, and less health care utilization than children in the other two treatment groups. Minority and poor children had the greatest amount of improvement using PFMs when symptomatic. Results were much less striking in white families. Thirty percent of families in the PFM treatment groups discontinued use entirely by 1 year postexit, whereas the majority of families who continued use (94%) used them only when symptomatic to inform symptom interpretation and management decisions. Conclusions Not every child with asthma needs a PFM. Children and families facing extra challenges as a result of illness severity, sociodemographic, or health care system characteristics clearly benefited most from PFM use.

The region surrounding the Llano de Chajnantor, a high altitude plateau in the Atacama Desert in northern Chile, has caught the attention of the astronomical community for its potential as an observatory site. Combining high elevation and extremely low atmospheric water content, the Llano has been chosen as the future site of the Atacama Large Millimeter Array. We have initiated a campaign to investigate the astronomical potential of the region in the optical/infrared. Here, we report on an aspect of our campaign aimed at establishing a seeing benchmark to be used as a reference for future activities in the region. After a brief description of the region and its climate, we describe the results of an astronomical seeing campaign, carried out with a Differential Image Motion Monitor that operates at 0.5 micron wavelength. The seeing at the Llano level of 5000 m, measured over 7 nights in May 1998, yielded a median FWHM of 1.1". However, the seeing decreased to 0.7" at a modest 100 m gain above the plateau (Cerro Chico), as measured over 38 nights spread between July 1998 and October 2000. Neither of these represents the best seeing expected in the region; the set of measurements provides a reference base for simultaneous dual runs at Cerro Chico and at other sites of interest in the region, currently underway. A comparison between simultaneous measurements at Cerro Chico and Cerro Paranal indicates that seeing at Cerro Chico is about 12% better than at Paranal. The percentage of optically photometric nights in the Chajnantor region is about 60%, while that of nights useful for astronomical work is near 80%., Comment: 29 pages, 8 figures, to appear in the PASP (July 2001)

Context.— A program of home visitation by nurses has been shown to affect the rates of maternal welfare dependence, criminality, problems due to use of substances, and child abuse and neglect. However, the long-term effects of this program on children’s antisocial behavior have not been examined. Objective.— To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on children’s antisocial behavior. Design.— Fifteen-year follow-up of a randomized trial. Interviews were conducted with the adolescents and their biological mothers or custodial parents. Setting.— Semirural community in New York. Participants.— Between April 1978 and September 1980, 500 consecutive pregnant women with no previous live births were recruited, and 400 were enrolled. A total of 315 adolescent offspring participated in a follow-up study when they were 15 years old; 280 (89%) were born to white mothers, 195 (62%) to unmarried mothers, 151 (48%) to mothers younger than 19 years, and 186 (59%) to mothers from households of low socioeconomic status at the time of registration during pregnancy. Intervention.— Families in the groups that received home visits had an average of 9 (range, 0-16) home visits during pregnancy and 23 (range, 0-59) home visits from birth through the child’s second birthday. The control groups received standard prenatal and well-child care in a clinic. Main Outcome Measures.— Children’s self-reports of running away, arrests, convictions, being sentenced to youth corrections, initiation of sexual intercourse, number of sex partners, and use of illegal substances; school records of suspensions; teachers’ reports of children’s disruptive behavior in school; and parents’ reports of the children’s arrests and behavioral problems related to the children’s use of alcohol and other drugs. Results.— Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances (incidence) of running away (0.24 vs 0.60; P = .003), fewer arrests (0.20 vs 0.45; P = .03), fewer convictions and violations of probation (0.09 vs 0.47; P,.001), fewer lifetime sex partners (0.92 vs 2.48; P = .003), fewer cigarettes smoked per day (1.50 vs 2.50; P = .10), and fewer days having consumed alcohol in the last 6 months (1.09 vs 2.49; P = .03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to use of alcohol and other drugs (0.15 vs 0.34; P = .08). There were no program effects on other behavioral problems. Conclusions.— This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families. JAMA. 1998;280:1238-1244 JUVENILE CRIME is a significant problem in the United States. In 1996, law enforcement agencies made 2.9 million arrests of juveniles (children ,18 years). Moreover, 19% of all arrests and 19% of all violent crime arrests were accounted for by juveniles. Although the number of juvenile Violent Crime Index arrests (ie, for murder, forcible rape, robbery, and aggravated assault) declined in both 1995 and 1996, the rate in 1996 was still 60% higher than the 1987 level. 1

In Reply .— Dr Glauber raises a common challenge to trials that examine a wide range of outcomes but do not make Bonferroni-like adjustments for multiple comparisons. We share Dr Glauber's concern about overinterpreting single statistically significant treatment differences. We have taken the position from the beginning of this program of research, however, that we generally would not make statistical adjustments for multiple comparisons. Instead, each of the 3 trials of this nurse home-visitor program has been guided by specific hypotheses grounded in a theoretical model; we treat with skepticism each treatment effect that meets the threshold of conventional statistical significance unless it coheres with other findings within the trial and with other relevant findings outside of the trial.1 Moreover, we have taken the position that findings from a single trial are an insufficient foundation for guiding policy or practice.1 Instead of making adjustments to P values, we have focused on conducting replication trials of the intervention with different populations across different contexts and time points in history. Questions of replicability, in our view, are of substantial importance from the standpoint of science and …

Blood lead levels in children have declined, and the level of concern specified by the Centers for Disease Control and Prevention now is 10 μg/dL. It is not clear, however, whether cognitive deficits consequent to lead exposure are a problem at blood lead levels less than 10 μg/dL. This study estimated blood lead concentrations in 172 children at ages 6, 12, 18, 24, 36, 48, and 60 months. At ages 3 and 5 years, the children were tested with the Stanford-Binet Intelligence Scale, an instrument that evaluates vocabulary, spatial pattern analysis, quantitative ability, and memory. Intelligence quotient (IQ) was related to blood lead levels after adjusting for maternal IQ, quality of the home environment, and other potentially confounding factors. Mean blood lead levels were lowest at age 6 months (3.4 μg/dL) and maximal at age 2 years (9.7 μg/dL). By age 5, the mean level was 6 μg/dL. The lifetime average blood lead level was 7.7 μg/dL at age 3 years and 7.4 μg/dL at age 5. The proportions of children with peak lead levels below 10 μg/dL were 57.0% and 55.8% at ages 3 and 5 years, respectively. At both these ages, the mean IQ (composite score) was approximately 90. After adjusting for numerous covariates, IQ correlated inversely and significantly with blood lead concentration. An increase in the lifetime average blood lead level of 1 μg/dL correlated with a change in IQ of -0.46. The estimated overall difference in IQ for each 1-μg/dL increase in lifetime average lead level was -1.37 points. Other significant predictors of IQ included maternal IQ, material income, and the child's birth weight. These findings suggest that substantially more children in the United States undergo adverse cognitive change from environmental exposure to lead than was previously thought. Primary prevention is essential in view of the lack of effective treatment for children with moderate blood lead elevations.

Union Electric Company is a summer peaking utility, experiencing peak electrical load demands during the hot summer months. Combustion turbine generators are often used to meet the summer peak demands. However, the generating capability of a combustion turbine decreases as the ambient air temperature increases. When system peak demands are at their highest levels on the hottest days of the year, the generating capacity of the combustion turbines are at their lowest values. This lost generating capacity can be recovered by cooling the air entering the combustion turbines. Various combustion turbine inlet air cooling technologies were investigated for a General Electric Model 7B combustion turbine. The cooling technologies evaluated in the study were evaporative cooling, thermal energy storage (ice), on-line mechanical chiller, direct absorption chiller, steam absorption chiller with heat recovery steam generator (HRSG), and once-through cooling using well water. Conceptual designs, performance estimates, installation and operating costs were developed for each alternative.

We commend Koller et al. (2004) for their thoughtful and detailed review of recent research on childhood lead exposure and intellectual development, and we take this opportunity to clarify and respond to several of their questions regarding our study of children with blood lead concentrations

ContextHome visitation to families with young children has been promoted as an effective way to prevent child maltreatment, but few studies have examined the conditions under which such programs meet this goal.ObjectiveTo investigate whether the presence of domestic violence limits the effects of nurse home visitation interventions in reducing substantiated reports of child abuse and neglect.DesignFifteen-year follow-up study of a randomized trial.SettingSemirural community in upstate New York.ParticipantsOf 400 socially disadvantaged pregnant women with no previous live births enrolled consecutively between April 1978 and September 1980, 324 mothers and their children participated in the follow-up study.InterventionsFamilies were randomly assigned to receive routine perinatal care (control group; n = 184 participated in follow-up), routine care plus nurse home visits during pregnancy only (n = 100), or routine care plus nurse home visits during pregnancy and through the child's second birthday (n = 116).Main Outcome MeasuresNumber of substantiated reports over the entire 15-year period involving the study child as subject regardless of the identity of the perpetrator or involving the mother as perpetrator regardless of the identity of the child abstracted from state records and analyzed by treatment group and level of domestic violence in the home as measured by the Conflict Tactics Scale.ResultsFamilies receiving home visitation during pregnancy and infancy had significantly fewer child maltreatment reports involving the mother as perpetrator (P = .01) or the study child as subject (P = .04) than families not receiving home visitation. The number of maltreatment reports for mothers who received home visitation during pregnancy only was not different from the control group. For mothers who received visits through the child's second birthday, the treatment effect decreased as the level of domestic violence increased. Of women who reported 28 or fewer incidents of domestic violence (79% of sample), home-visited mothers had significantly fewer child maltreatment reports during the 15-year period than mothers not receiving the longer-term intervention (P = .01). However, this intervention did not significantly reduce child maltreatment among mothers reporting more than 28 incidents of domestic violence (21% of sample).ConclusionsThe presence of domestic violence may limit the effectiveness of interventions to reduce incidence of child abuse and neglect.

This article describes a 20-year program of research on the Nurse Home Visitation Program, a model in which nurses visit mothers beginning during pregnancy and continuing through their children's second birthdays to improve pregnancy outcomes, to promote children's health and development, and to strengthen families' economic self-sufficiency. The results of two randomized trials (one in Elmira, New York, and the second in Memphis, Tennessee) are summarized, and an ongoing trial in Denver, Colorado, is briefly described. Results of the Elmira and Memphis trials suggest the following: The program benefits the neediest families (low-income unmarried women) but provides little benefit for the broader population. Among low-income unmarried women, the program helps reduce rates of childhood injuries and ingestions that may be associated with child abuse and neglect, and helps mothers defer subsequent pregnancies and move into the workforce. Long-term follow-up of families in Elmira indicates that nurse-visited mothers were less likely to abuse or neglect their children or to have rapid successive pregnancies. Having fewer children enabled women to find work, become economically self-sufficient, and eventually avoid substance abuse and criminal behavior. Their children benefitted too. By the time the children were 15 years of age, they had had fewer arrests and convictions, smoked and drank less, and had had fewer sexual partners. The program produced few effects on children's development or on birth outcomes, except for children born to women who smoked cigarettes when they registered during pregnancy. The positive effects of the program on child abuse and injuries to children were most pronounced among mothers who, at registration, had the lowest psychological resources (defined as high levels of mental health symptoms, limited intellectual functioning, and little belief in their control of their lives). Generally, effects in Elmira were of greater magnitude and covered a broader range of outcomes than in Memphis, perhaps because of differences between the populations studied, community contexts, or a higher rate of turnover among home visitors in Memphis than in Elmira. The article concludes that the use of nurses as home visitors is key; that services should be targeted to the neediest populations, rather than being offered on a universal basis; that clinically tested methods of changing health and behavioral risks should be incorporated into program protocols; and that services must be implemented with fidelity to the model tested if program benefits found in scientifically controlled studies are to be reproduced as the program is replicated in new communities.

Home-visitation services have been promoted as a means of improving maternal and child health and functioning. However, long-term effects have not been examined.To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on women's life course and child abuse and neglect.Randomized trial.Semirural community in New York.Of 400 consecutive pregnant women with no previous live births enrolled, 324 participated in a follow-up study when their children were 15 years old.Families received a mean of 9 home visits during pregnancy and 23 home visits from the child's birth through the second birthday. DATA SOURCES AND MEASURES: Women's use of welfare and number of subsequent children were based on self-report; their arrests and convictions were based on self-report and archived data from New York State. Verified reports of child abuse and neglect were abstracted from state records.During the 15-year period after the birth of their first child, in contrast to women in the comparison group, women who were visited by nurses during pregnancy and infancy were identified as perpetrators of child abuse and neglect in 0.29 vs 0.54 verified reports (P.001). Among women who were unmarried and from households of low socioeconomic status at initial enrollment, in contrast to those in the comparison group, nurse-visited women had 1.3 vs 1.6 subsequent births (P=.02), 65 vs 37 months between the birth of the first and a second child (P=.001), 60 vs 90 months' receiving Aid to Families With Dependent Children (P=.005), 0.41 vs 0.73 behavioral impairments due to use of alcohol and other drugs (P=.03), 0.18 vs 0.58 arrests by self-report (P.001), and 0.16 vs 0.90 arrests disclosed by New York State records (P.001).This program of prenatal and early childhood home visitation by nurses can reduce the number of subsequent pregnancies, the use of welfare, child abuse and neglect, and criminal behavior on the part of low-income, unmarried mothers for up to 15 years after the birth of the first child.

LONG-TERM EFFECTS OF EARLY HOME VISITATION ON MOTHER'S USE OF WELFARE AND RATES OF SUBSEQUENT BIRTHS. • 645

Objective. To examine the relationship between maternal cigarette smoking during pregnancy and children's intellectual functioning during the first 4 years of life. Design. Prospective follow-up of participants in a randomized trial of pregnancy and infancy nurse home visitation. Setting. Semirural community in Upstate New York. Participants. 400 families in which the mothers registered before the 30th week of pregnancy and had no previous live births. Eighty-five percent of the mothers were either teenagers ( Main results. Children in the comparison group whose mothers smoked 10 or more cigarettes per day during pregnancy had Stanford-Binet scores at 3 and 4 years of age that were 4.35 (95% CI: 0.02, 8.68) points lower (after controlling for a wide range of variables) than their counterparts whose mothers did not smoke during pregnancy. Conclusions. The results of this study add to the increasingly consistent evidence that maternal cigarette smoking during pregnancy poses a unique risk for neurodevelopmental impairment among children and provide an additional reason for pregnant women not to smoke cigarettes.