Federally qualified health centers reduce the primary care provider gap in health professional shortage counties.

BACKGROUND: Federally qualified health centers (FQHCs) were designed to provide care in medically underserved areas. Substantial and sustained federal funding has accelerated FQHC growth. PURPOSE: To examine temporal trends in primary care provider supply and whether FQHCs have been successful in reducing the gap in provider supply in primary care health professional shortage areas (HPSAs). METHODS: Retrospective cohort study design using national county-level data from 2009 to 2013. Primary care providers included physicians, nurse practitioners, and physician assistants. FINDINGS: Partial-county HPSAs had the highest average provider supply and the greatest increase, followed by non-HPSA counties and whole-county HPSAs. The provider gap was larger in whole-county HPSAs compared with partial-county HPSAs. Counties with one or more FQHC sites had a smaller provider gap than those without FQHC sites. An increase of one FQHC site was statistically significantly associated with a reduction in the annual provider gap. DISCUSSION: FQHCs reduced the gap in primary care provider supply in shortage counties and mitigated uneven distribution of the primary care workforce.

Improving student nurses' confidence in managing the acutely ill patient.

AIM: the Acute Illness Management (AIM) course was introduced into NHS trusts across Greater Manchester in 2002/03 for registered nurses. In preparation for the transition from student to registered nurse, the AIM course was then included in the final year of the undergraduate nursing programme. The aim of this study was to evaluate the impact of the AIM course on student nurses' confidence in managing the acutely ill patient. METHOD: a quantitative approach was adopted. Ethical approval was granted by the Research and Ethics committee at the University of Salford. RESULTS: a total of 192 student nurses attended the AIM course; 94% of the students completed a pre-course questionnaire and 100% completed the post-course questionnaire. CONCLUSION: the evidence suggests a significant increase in the student nurses' confidence in recognising, responding and managing an acutely ill patient following the one-day course.

Process Evaluation of a Comprehensive Supermarket Intervention in a Low-Income Baltimore Community.

Supermarket-based interventions are one approach to improving the local food environment and reducing obesity and chronic disease in low-income populations. We implemented a multicomponent intervention that aimed to reduce environmental barriers to healthy food purchasing in a supermarket in Southwest Baltimore. The intervention, Eat Right-Live Well! used: shelf labels and in-store displays promoting healthy foods, sales and promotions on healthy foods, in-store taste tests, increasing healthy food products, community outreach events to promote the intervention, and employee training. We evaluated program implementation through store environment, taste test session, and community event evaluation forms as well as an Employee Impact Questionnaire. The stocking, labeling, and advertising of promoted foods were implemented with high and moderate fidelity. Taste test sessions were implemented with moderate reach and low dose. Community outreach events were implemented with high reach and dose. Supermarket employee training had no significant impact on employees' knowledge, self-efficacy, or behavioral intention for helping customers with healthy purchasing or related topics of nutrition and food safety. In summary, components of this intervention to promote healthy eating were implemented with varying success within a large supermarket. Greater participation from management and employees could improve implementation.

Factors influencing glove use in student nurses.

BACKGROUND: Gloves can prevent infection but their use among student nurses is inconsistent. AIM: To explore pre-registration student nurses' views of non-sterile glove use in clinical practice. METHOD: An online survey was conducted and focus groups carried out among third-year student nurses. RESULTS: The online survey showed that gloves were often worn inappropriately, while the focus groups revealed students conformed to their mentors' use of gloves. DISCUSSION: Student nurses' decisions on wearing gloves seem to be based on the culture of the clinical care environment rather than trust policy. Glove overuse deprives patients of therapeutic touch and may lead to contact dermatitis in nurses. CONCLUSION: All student nurses must be able to identify clinical situations when gloves are not indicated, using appropriate risk assessment.

Early Home Visits and Health Outcomes in Low-Income Mothers and Offspring: 18-Year Follow-Up of a Randomized Clinical Trial.

Importance: Individuals with low income may have heightened rates of obesity and hypertension. Objective: To determine whether prenatal and infancy home visitation by nurses reduces maternal and offspring obesity and hypertension. Design, Setting, and Participants: This randomized clinical trial of prenatal and infancy nurse home visitation in a public health care system in Memphis, Tennessee, enrolled 742 women with no previous live births and at least 2 sociodemographic risk factors (unmarried, <12 years of education, unemployed) from June 1, 1990, through August 31, 1991. At registration during pregnancy, 727 mothers (98%) were unmarried, and 631 (85%) lived below the federal poverty level. At offspring ages 12 and 18 years, maternal and offspring obesity and hypertension were assessed by staff masked to treatment. The data analysis was performed from July 1, 2021, to October 31, 2023. Interventions: Women assigned to the control group received free transportation for prenatal care and child developmental screening and referral at child ages 6, 12, and 24 months. Women assigned to nurse visitation received transportation and screening plus prenatal and infant and toddler nurse home visits. Main Outcomes and Measures: Obesity and hypertension among mothers and their offspring at child ages 12 and 18 years, although not hypothesized in the original trial design, were analyzed using post-double selection lasso method. Results: Of the 742 participants randomized (mean [SD] age, 18.1 [3.2] years), interviews were completed with 594 mothers and 578 offspring at child age 12 years and 618 mothers and 629 offspring at child age 18 years. Obesity was assessed for 576 offspring at age 12 years and 605 at age 18 years and for 563 and 598 mothers at child ages 12 and 18 years, respectively. Blood pressure was assessed for 568 offspring aged 12 years and 596 aged 18 years and 507 and 592 mothers at child ages 12 and 18 years, respectively. There were no overall treatment-control differences in offspring obesity or hypertension at ages 12 and 18 years combined, although nurse-visited female offspring, compared with controls, had a lower prevalence of obesity (adjusted relative risk [ARR], 0.449; 95% CI, 0.234-0.858; P = .003) and severe obesity (ARR, 0.185; 95% CI, 0.046-0.748; P < .001). There were reductions at ages 12 and 18 years combined for stage 1 and stage 2 hypertension for nurse-visited vs control group mothers, with differences limited to mothers of females (stage 1: ARR, 0.613 [95% CI, 0.440-0.855; P = .001]; stage 2: ARR, 0.217 [95% CI, 0.081-0.582; P < .001]). For both obesity and hypertension outcomes, there was no intervention effect among male offspring or the mothers of males. Self-reported maternal health aligned with program effects on hypertension. Conclusions and Relevance: In this clinical trial follow-up at offspring ages 12 and 18, nurse-visited female offspring had lower rates of obesity and mothers of females had lower rates of hypertension than control-group counterparts. These findings suggest that risks for chronic disease among mothers of females and their female offspring who live in extreme poverty may be prevented with prenatal and infant and toddler home visitations by nurses. Trial Registration: ClinicalTrials.gov Identifier: NCT00708695.

Evaluation and deployment of isotype-specific salivary antibody assays for detecting previous SARS-CoV-2 infection in children and adults.

BACKGROUND: Saliva is easily obtainable non-invasively and potentially suitable for detecting both current and previous SARS-CoV-2 infection, but there is limited evidence on the utility of salivary antibody testing for community surveillance. METHODS: We established 6 ELISAs detecting IgA and IgG antibodies to whole SARS-CoV-2 spike protein, to its receptor binding domain region and to nucleocapsid protein in saliva. We evaluated diagnostic performance, and using paired saliva and serum samples, correlated mucosal and systemic antibody responses. The best-performing assays were field-tested in 20 household outbreaks. RESULTS: We demonstrate in test accuracy (N = 320), spike IgG (ROC AUC: 95.0%, 92.8-97.3%) and spike IgA (ROC AUC: 89.9%, 86.5-93.2%) assays to discriminate best between pre-pandemic and post COVID-19 saliva samples. Specificity was 100% in younger age groups (0-19 years) for spike IgA and IgG. However, sensitivity was low for the best-performing assay (spike IgG: 50.6%, 39.8-61.4%). Using machine learning, diagnostic performance was improved when a combination of tests was used. As expected, salivary IgA was poorly correlated with serum, indicating an oral mucosal response whereas salivary IgG responses were predictive of those in serum. When deployed to household outbreaks, antibody responses were heterogeneous but remained a reliable indicator of recent infection. Intriguingly, unvaccinated children without confirmed infection showed evidence of exposure almost exclusively through specific IgA responses. CONCLUSIONS: Through robust standardisation, evaluation and field-testing, this work provides a platform for further studies investigating SARS-CoV-2 transmission and mucosal immunity with the potential for expanding salivo-surveillance to other respiratory infections in hard-to-reach settings.

If a person has been previously infected with SARS-CoV-2 they will produce specific proteins, called antibodies. These are present in the saliva and blood. Saliva is easier to obtain than blood, so we developed and evaluated six tests that detect SARS-CoV-2 antibodies in saliva in children and adults. Some tests detected antibodies to a particular protein made by SARS-CoV-2 called the spike protein, and these tests worked best. The most accurate results were obtained by using a combination of tests. Similar tests could also be developed to detect other respiratory infections which will enable easier identification of infected individuals.

Finite element aortic injury reconstruction of near side lateral impacts using real world crash data.

Traumatic rupture of the aorta (TRA) remains the second most common cause of death associated with motor vehicle crashes, only less prevalent than brain injury. On average, nearly 8000 people die annually in the United States due to blunt injury to the aorta. It is observed that over 80% of occupants who suffer an aortic injury die at the scene due to exsanguination into the chest cavity. In the current study, eight near side lateral impacts, in which TRA occurred, were reconstructed using a combination of real world crash data reported in the Crash Injury Research and Engineering Network (CIREN) database, finite element (FE) models of vehicles, and the Wayne State Human Body Model - II (WSHBM). For the eight CIREN cases reconstructed, the high strain regions in the aorta closely matched with the autopsy data provided. The peak average maximum principal strains in all of the eight CIREN cases were localized in the isthmus region of the aorta, distal to the left subclavian artery, and averaged at 22 ± 6.2% while the average maximum pressure in the aorta was found to be 117 ± 14.7 kPa.

Internet recruitment and retention for a 6 months' longitudinal study.

PURPOSE: To examine factors influencing recruitment and retention of study participants in a longitudinal study. METHODS: After completion of a longitudinal (6 months) study of long-term indwelling urinary catheter users, three types of data were analyzed: number of problems with data entry into an online survey, number of reminders sent by study staff to participants, and number and nature of e-mail contacts between participants and study staff and among study staff regarding the study. CONCLUSIONS: The Internet can be used effectively for research, especially involving small, specialized populations. In order to retain study subjects and obtain complete and accurate data, study staff must be closely involved and responsive to participants' issues, and technical support staff must be readily available and invested in the research project. CLINICAL RELEVANCE: Using the Internet to reach small, special, marginalized, or geographically dispersed populations for research is becoming common. Researchers need to know how best to recruit, support, and retain participants in Internet-based studies.

Randomized controlled trial of CARE: an intervention to improve outcomes of hospitalized elders and family caregivers.

In this randomized controlled trial we tested the efficacy of an intervention program (CARE: Creating Avenues for Relative Empowerment) for improving outcomes of hospitalized older adults and their family caregivers (FCGs). FCG-patient dyads (n = 407) were randomized into two groups. The CARE group received a two-session empowerment-educational program 1-2 days post-admission and 1-3 days pre-discharge. The attention control group received a generic information program during the same timeframe. Follow-up was at 2 weeks and 2 months post-discharge. There were no statistically significant differences in patient or FCG outcomes. However, inconsistent evidence of role outcome differences suggests that CARE may benefit certain FCG subgroups instead of being a one-size-fits-all intervention strategy. Closer examination of CARE's mechanisms and effects is needed.

Development and evaluation of low-volume tests to detect and characterize antibodies to SARS-CoV-2.

Low-volume antibody assays can be used to track SARS-CoV-2 infection rates in settings where active testing for virus is limited and remote sampling is optimal. We developed 12 ELISAs detecting total or antibody isotypes to SARS-CoV-2 nucleocapsid, spike protein or its receptor binding domain (RBD), 3 anti-RBD isotype specific luciferase immunoprecipitation system (LIPS) assays and a novel Spike-RBD bridging LIPS total-antibody assay. We utilized pre-pandemic (n=984) and confirmed/suspected recent COVID-19 sera taken pre-vaccination rollout in 2020 (n=269). Assays measuring total antibody discriminated best between pre-pandemic and COVID-19 sera and were selected for diagnostic evaluation. In the blind evaluation, two of these assays (Spike Pan ELISA and Spike-RBD Bridging LIPS assay) demonstrated >97% specificity and >92% sensitivity for samples from COVID-19 patients taken >21 days post symptom onset or PCR test. These assays offered better sensitivity for the detection of COVID-19 cases than a commercial assay which requires 100-fold larger serum volumes. This study demonstrates that low-volume in-house antibody assays can provide good diagnostic performance, and highlights the importance of using well-characterized samples and controls for all stages of assay development and evaluation. These cost-effective assays may be particularly useful for seroprevalence studies in low and middle-income countries.

Analysis of the mechanism of lateral impact aortic isthmus disruption in real-life motor vehicle crashes using a computer-based finite element numeric model: with simulation of prevention strategies.

INTRODUCTION: Despite advances in the surgical therapy of aortic injury (AI) using endovascular prostheses, more than 60% of motor vehicle crash (MVC) induced AIs die at the scene. In 80 cases of MVC AI, both change in velocity on impact (Delta V) and impact energy (IE) were correlated with autopsy or surgical findings. Of the 34 AIs due to lateral impact MVCs (LMVC), 91% had an aortic isthmus laceration. Computer simulation is used to study the cause of LMVC AI. METHODS: To delineate AI mechanism, 10 real life LMVCs (8 left, 2 right) were simulated using a computer-based finite element numerical model. Each began with the initial vehicle impact with another vehicle or fixed object, followed by the vehicle's compartment structures' impact with the patient's chest wall, causing a rise in intra-aortic pressure and the resulting location and pattern of aortic wall stresses and strains. In the real LMVCs, the Delta V ranged from 27.5 to 62 kph with impact energies of from 46,051 to 313,502 joules. In both real-life and the model, the main cause of the chest wall impact was intrusion of the car's B-pillar. Dynamic simulations delineate increased stress and strains at the aortic Isthmus. In some LMVCs, the B-pillar intrusion was also seen to impact the head in the AI cases. RESULTS: In the simulations, aortic pressure rose from 100 mm Hg precrash to as high as 1,322 mm Hg. Both the maximum aortic longitudinal tensile strain and the von Mises Stress were proportional to the maximum force impacted on the chest wall. Aortic isthmus maximum stresses ranged from 1.1 Mega Pascal (MPa) to 3.2 MPa, with longitudinal tensile strains ranging from 8.2% to 48.5%. The simulation dynamics demonstrated that the proximal pressurized turgid aorta initially moves toward the LMVC impact. As a result, the ascending aorta and aortic arch (proximal ascending aorta) rotate about the fulcrum of the great vessels, so that this aortic unit, acting as the long-arm of an Archimedes lever system, exerts the maximum stress and strain at the aortic isthmus or short-arm, where the real-life aortic rupture occurs. CONCLUSION: Simulation supports the lever hypothesis that the force on the short-arm aortic isthmus is proportionally greater than at the long-arm proximal aorta. Simulation also suggests improved vehicle construction techniques, which increase the strength and resistance to deformation of the B-pillar and vehicle side structure plus a B-pillar airbag will limit the intrusion forces causing LMVC AIs and reduce the incidence of associated head injuries.

Study on the use of long-term urinary catheters in community-dwelling individuals.

PURPOSE: The purpose of this study was to determine the incidence and distribution of catheter-related problems in long-term indwelling urinary catheter users. We also sought to assess appropriateness of catheter use and examine relationships among catheter complications and catheter care practices. DESIGN: This repeated-measures study involved self-reported data collection by recall at intake and by prospective data collection at 2, 4, and 6 months in long-term urinary catheter users. SUBJECTS AND SETTING: Two sampling arms were used: a home care (HC) agency with 10 individuals and the Internet with 33 people having spinal cord injury. METHODS: Home visit and follow-up telephone call interviews were used with the participants from the HC agency. Data were self-administered through SurveyMonkey in the Internet sample, and communication was through e-mail, telephone, and postal mail. Analysis included descriptive statistics and generalized estimating equation techniques to adjust for within-subject variation over time. RESULTS: All study participants had at least 1 catheter-related problem during 8 months, and many had multiple, recurring problems. Catheter-associated urinary tract infection (CAUTI) was reported by 70%, blockage by 74%, leakage by 79%, and accidental dislodgement by 33%. Key tests of associations (generalized estimating equation) predicted that catheter size contributed to CAUTI, with significant covariates of female gender and younger age. The presence of sediment in the urine on the day of the survey predicted catheter blockage. CONCLUSION: The incidence of all complications was higher than expected. Problems associated with long-term indwelling catheter use may contribute to excess healthcare utilization adversely affecting both users and their families.

Reducing Cardiovascular Disease Risk for Employees Through Participation in a Wellness Program.

The objective was to evaluate the long-term impact that the University of Rochester Employee Wellness program has made in reducing cardiovascular disease risk. The authors conducted a 5-year retrospective study to measure change in health outcomes for more than 16,000 employees who participated in the program for more than 1 year between January 2013 and December 2017. A logistic regression model was applied to estimate the impact of participation on improvement in cardiovascular disease risk. Statistically significant improvement was found in the health of participants. Almost 50% of all program participants, having moderate-to-high risk at baseline, improved their 10-year cardiovascular disease risk. Moreover, about a third of participants improved by a full risk category. Engagement in a condition management program also was found to increase the odds of improvement by 36%. The integrated approach to wellness can improve the long-term health of participants and reduce their risk of developing cardiovascular disease by achieving long-term improved lifestyle behaviors. Employers, employee benefits brokers, and insurance companies need to assess wellness programs by their performance and by their design, specifically as it relates to long-term outcomes.

A pilot study of dose-dense adjuvant paclitaxel without growth factor support for women with early breast carcinoma.

PURPOSE: Granulocyte-colony stimulating factor (G-CSF) was used in CALGB 9741 to support dose-dense sequential chemotherapy with doxorubicin and cyclophosphamide (AC) followed by paclitaxel (P) (Citron et al. J Clin Oncol 21:1431-1439, 2003). However, myelosuppression is not known to be dose or schedule limiting for paclitaxel. We therefore conducted this trial to determine the need for routine G-CSF, using the pegylated product (pG-CSF), support during the paclitaxel component of dose-dense sequential chemotherapy in women with early stage breast carcinoma (BC). PATIENTS AND METHODS: Eligible patients received dose-dense chemotherapy consisting of four cycles of AC followed by four cycles of P at two week intervals. pG-CSF (Neulasta) was administered after each of four cycles of AC but was held after P. Planned enrollment was 59 pts. RESULTS: Of the first 15 patients, nine completed therapy without delays due to neutropenia but 6 (40%) did not, leading to implementation of the pre-specified early termination rule. Overall, 85% of P doses were successfully delivered on time. The mean treatment delay for the entire group due to neutropenia was 0.75 days. There was no significant correlation between neutropenia and prior WBC, ANC, or concurrent treatment with trastuzumab. Pts with neutropenia tended to be younger (Mean age 43.5) and have a lower BSA (1.65 m(2)). There were no febrile episodes due to omission of pG-CSF. CONCLUSION: When paclitaxel is administered in a dose-dense fashion without growth factor support brief treatment delays are common. Further study is needed to identify the minimal pG-CSF administration that will avoid treatment delays.

How to measure a patient's temperature non-invasively.

RATIONALE AND KEY POINTS: Temperature is a vital sign that is included in all early warning scoring tools and as part of patient observations. This article outlines the main non-invasive methods that can be used to measure a patient's temperature. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

Prenatal and Infancy Nurse Home Visiting Effects on Mothers: 18-Year Follow-up of a Randomized Trial.

BACKGROUND: Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources. METHODS: We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects. RESULTS: Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs. CONCLUSIONS: Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

Prenatal and Infancy Nurse Home Visiting and 18-Year Outcomes of a Randomized Trial.

OBJECTIVES: Given earlier effects found in randomized clinical trials of the Nurse-Family Partnership, we examined whether this program would improve 18-year-old first-born youths' cognition, academic achievement, and behavior and whether effects on cognitive-related outcomes would be greater for youth born to mothers with limited psychological resources (LPR) and on arrests and convictions among females. METHODS: We enrolled 742 pregnant, low-income women with no previous live births and randomly assigned them to receive either free transportation for prenatal care plus child development screening and referral (control; n = 514) or prenatal and infant home nurse visit (NV) plus transportation and screening (n = 228). Assessments were completed on 629 18-year-old first-born offspring to evaluate these primary outcomes: (1) cognitive-related abilities (nonverbal intelligence, receptive language, and math achievement) and (2) behavioral health (internalizing behavioral problems, substance use and abuse, sexually transmitted infections, HIV risk, arrests, convictions, and gang membership). RESULTS: Compared with control-group counterparts, NV youth born to mothers with LPR had better receptive language (effect size = 0.24; 95% confidence interval [CI]: 0.00 to 0.47; P = .05), math achievement (effect size = 0.38; 95% CI: 0.14 to 0.61; P = .002), and a number of secondary cognitive-related outcomes. NV females, as a trend, had fewer convictions (incidence ratio = 0.47; 95% CI: 0.20 to 1.11; P = .08). There were no intervention effects on other behaviors. CONCLUSIONS: The program improved the cognitive-related skills of 18-year-olds born to mothers with LPR and, as a trend, reduced female convictions but produced no other effects on youth behavioral health.

An Exploration of the Determinants of Gestational Weight Gain in African American Women: Genetic Factors and Energy Expenditure.

BACKGROUND: Excessive gestational weight gain (GWG) has a long-term impact on women's body weight and contributes to the development of obesity in the mother and her child. Many risk factors for GWG have been identified, but to date, only 6-33.8% of the variance in GWG has been explained. The purpose of this study was to evaluate the overall variance of GWG that can be explained by including weight-adjusted resting metabolic rate (aRMR) and a genetic risk score constructed on obesity-related genes in addition to sociodemographic and lifestyle factors. METHODS: In this observational study involving 55 African American women, data collected/measured during pregnancy included sociodemographic factors, medical information, lifestyle factors, aRMR, and seven obesity-related genes. Multivariable linear regression was performed to evaluate the variance in GWG explained by the potential risk factors listed above. RESULTS: The mean GWG was 15 kg (±7.5 kg), and 63.6% of women gained more than the Institute of Medicine's GWG recommendations. The final regression model explained 53.3% of the variance in GWG. Higher genetic risk score, lower aRMR, and higher dietary intake of total energy and percentage of fat were significantly associated with increased GWG ( p < .05). These factors explained 18% additional variance in GWG over that explained by significant sociodemographic and lifestyle factors in the analysis (i.e., maternal age, prepregnancy body mass index, parity, illegal drug use, and education). CONCLUSION: Overall, our results indicate that the genetic risk score, aRMR, and dietary intake have a substantial impact on GWG in African American women.

Low birthweight in second children after nurse home visiting.

OBJECTIVE: To examine low birthweight and preterm birth of second children born to home-visited first-time mothers. SUBJECTS: Women were previously recruited for a randomized controlled trial of the home visiting model disseminated as Nurse-Family Partnership. 512 of these women had second children within 18 years of the first child's birth, and were included in our sample. RESULTS: The intervention was associated with a lower likelihood of low birthweight for second children (odds ratio: 0.51, 95% CI: 0.27, 0.97), an effect apparent only if the first-born had low birthweight and mediated by close birth spacing. These moderation and mediation patterns were similar in the preterm birth outcome. CONCLUSION: A home visiting program provided for first-born children reduced low birthweight for second-born children, if the first-born had low birthweight. This finding implies a broader impact than previously documented, because few studies have included these second children.