Interprofessional care in a retirement and assisted living community: the complexity of teamwork.

Teamwork is an aspiration in the delivery of interprofessional care to older adults, but how does it play out in residential settings that combine independent living, assisted living, and skilled nursing care? This study investigated teamwork as an organic part of a retirement and assisted living community immersed in mission-driven care. Drawing on 44 in-depth interviews, 62 meeting observations, and five years of immersion in the setting by the first author, we explored the complex dynamics of teamwork. Our overarching findings showed that co-location aided by physical design and a mission-driven investment in care may not be sufficient to effect teamwork in a complex care environment, and that the organizational context was potentially damaging to teamwork. Our study highlights opportunities to improve teamwork and interprofessional collaboration in organizational settings that combine the provision of health and social care. Increasing expectations for teamwork outcomes may prove essential as retirement and assisted living care settings offer supportive and therapeutic environments for older adults who move between different levels of care.

SARS-CoV-2 in residential rooms of two self-isolating persons with COVID-19.

Individuals with COVID-19 are advised to self-isolate at their residences unless they require hospitalization. Persons sharing a dwelling with someone who has COVID-19 have a substantial risk of being exposed to the virus. However, environmental monitoring for the detection of virus in such settings is limited. We present a pilot study on environmental sampling for SARS-CoV-2 virions in the residential rooms of two volunteers with COVID-19 who self-quarantined. Apart from standard surface swab sampling, based on availability, four air samplers positioned 0.3-2.2 m from the volunteers were used: a VIable Virus Aerosol Sampler (VIVAS), an inline air sampler that traps particles on polytetrafluoroethylene (PTFE) filters, a NIOSH 2-stage cyclone sampler (BC-251), and a Sioutas personal cascade impactor sampler (PCIS). The latter two selectively collect particles of specific size ranges. SARS-CoV-2 RNA was detected by real-time Reverse-Transcription quantitative Polymerase Chain Reaction (rRT-qPCR) analyses of particles in one air sample from the room of volunteer A and in various air and surface samples from that of volunteer B. The one positive sample collected by the NIOSH sampler from volunteer A's room had a quantitation cycle (Cq) of 38.21 for the N-gene, indicating a low amount of airborne virus [5.69E-02 SARS-CoV-2 genome equivalents (GE)/cm3 of air]. In contrast, air samples and surface samples collected off the mobile phone in volunteer B's room yielded Cq values ranging from 14.58 to 24.73 and 21.01 to 24.74, respectively, on the first day of sampling, indicating that this volunteer was actively shedding relatively high amounts of SARS-CoV-2 at that time. The SARS-CoV-2 GE/cm3 of air for the air samples collected by the PCIS was in the range 6.84E+04 to 3.04E+05 using the LED-N primer system, the highest being from the stage 4 filter, and similarly, ranged from 2.54E+03 to 1.68E+05 GE/cm3 in air collected by the NIOSH sampler. Attempts to isolate the virus in cell culture from the samples from volunteer B's room with the aforementioned Cq values were unsuccessful due to out-competition by a co-infecting Human adenovirus B3 (HAdVB3) that killed the Vero E6 cell cultures within 4 days of their inoculation, although Cq values of 34.56-37.32 were measured upon rRT-qPCR analyses of vRNA purified from the cell culture medium. The size distribution of SARS-CoV-2-laden aerosol particles collected from the air of volunteer B's room was >0.25 µm and >0.1 µm as recorded by the PCIS and the NIOSH sampler, respectively, suggesting a risk of aerosol transmission since these particles can remain suspended in air for an extended time and travel over long distances. The detection of virus in surface samples also underscores the potential for fomite transmission of SARS-CoV-2 in indoor settings.

Trends in utilisation of plain X-rays by older Australians (2010-2019).

BACKGROUND: Older Australians are major health service users and early diagnosis is key in the management of their health. Radiological services are an important component of diagnosis and disease management planning in older Australians, but their national utilisation of diagnostic services has never been investigated in Australia. PURPOSE: This study aims to evaluate the utilisation of major plain X-rays by Australians ≥ 65 years old. METHODS: A population-based epidemiological evaluation and yearly cross-sectional analyses of X-ray examinations per 1,000 Australians aged ≥ 65 years old between 2009 and 2019 were conducted using publicly available Medicare Benefits Schedule and Australian Bureau of Statistics data sources. Age and sex specific incidence rate (IR) of plain X-rays per 1,000 Australians, adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using a negative binomial regression model. RESULTS: During the study period, the Australian population over 65 years old increased by 39% while the crude plain X-ray utilisation by this population increased by 63%. Most X-rays were conducted on extremities or the chest. Men used chest radiography more than women, and particularly for lungs, where the incidence increased the most in those ≥ 85 years old. There was an increase in X-rays of extremities and the hip joint between 2009-10 and 2013-14 in people ≥ 85 years old. CONCLUSION: The utilisation of plain X-rays of the chest, the gastro-intestinal tract and extremities was high and has increased among older Australians between 2009-10 and 2018-19. Plain X-rays remain a commonly used diagnostic tool for conditions affecting the older population.

Elder maltreatment in Europe and the United States: a transnational analysis of prevalence rates and regional factors.

We investigated the association between type and frequency of elder maltreatment (EM) and residential setting (rural, suburban, and urban settings in the U.S. and northern and southern cities in Europe). We used data on 7,225 participants from European and U.S. cross-sectional studies to estimate rates of EM in three domains in the five settings in logistic-linear models that included setting and demographic variables and tested prespecified contrasts on settings. Northern Europe is similar to the U.S. in rate of financial exploitation; the Mediterranean has higher rates than either of the other two. For emotional and physical maltreatment, the Mediterranean is similar to the U.S; Northern Europe has higher rates. EM differs between and within settings in the U.S. and Europe. There is a need for rigorous research to examine the effects of residential settings and environment on EM. Interventions to reduce EM should be explored.

Neighborhood Social Context and Kidney Function Over Time: The Multi-Ethnic Study of Atherosclerosis.

RATIONALE & OBJECTIVE: Although socioeconomic status has been associated with chronic kidney disease (CKD), little is known about its relationship to residential neighborhood context. STUDY DESIGN: Secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study designed to investigate the development and progression of subclinical cardiovascular disease. SETTING & PARTICIPANTS: 6,814 men and women who were between 45 and 84 years of age and free of cardiovascular disease were recruited between 2000 and 2002 from Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles, CA; New York, NY; and St. Paul, MN. EXPOSURES: A composite neighborhood problem score (calculated based on 7 participant-reported domains at study entry: adequacy of food sources, availability of parks/playground, noise, sidewalks, traffic, trash and litter, and violence) and a social cohesion score (calculated based on 5 participant-reported attributes of people in their neighborhood: close knit; get along; willing to help neighbors; trustworthy; and share values). OUTCOMES: Estimated glomerular filtration rate (eGFR; calculated using the CKD-EPI [CKD Epidemiology Collaboration] creatinine-cystatin C equation) and an indicator of eGFR decline > 30% since study entry using follow-up eGFR quantified at 4 examinations: 2000 to 2002, 2004 to 2005, 2005 to 2007, and 2010 to 2011. ANALYTICAL APPROACH: Associations between each neighborhood measure (in separate models) and eGFR decline > 30% from baseline and annualized eGFR change were estimated using Cox proportional hazards and linear mixed regression models, respectively, adjusting for potential confounders. RESULTS: While neighborhood social context differs by race/ethnicity, neither neighborhood problems nor social cohesion was independently associated with eGFR decline after adjustment for confounders. LIMITATIONS: Incomplete capture of the early stages of eGFR decline, reliance on observational data, limited variation in neighborhood measures, and the potential for residual confounding. CONCLUSIONS: Although we showed no independent association between neighborhood context and eGFR decline, it is associated with many CKD risk factors and further work is needed to clarify whether it has an independent role in CKD.

Health effects of wind turbines on humans in residential settings: Results of a scoping review.

INTRODUCTION: As the global number of wind turbines has increased steadily in recent years, as has the number of studies about putative health effects in residential settings, it is the review purpose to give an overview of the characteristics and methodologies of the scientific literature around the topic in order to identify research gaps and to derive implications for research and practice. Additionally, study findings from higher-quality observational studies as well as results that seem to be of interest for the scientific and political debate are presented. METHODS: The scoping review was conducted following systematic review methods. Comprehensive literature searches were carried out in several databases, and with extensive hand searches. All review steps were carried out in parallel by two reviewers or by one reviewer and in duplicate checked by another reviewer. The following important methodological criteria were investigated: Reporting, ethical aspects, generalization, selection bias, information bias, confounder bias. Findings from observational studies without a selection bias, information bias, and confounder bias are presented. RESULTS: 84 articles, that varied significantly in methods and outcomes assessed, met the inclusion criteria. Multiple cross-sectional studies reported that wind turbine noise is associated with noise annoyance, which is moderated by several variables such as noise sensitivity, attitude towards wind turbines, or economic benefit. Wind turbine noise is not associated with stress effects and biophysiological variables of sleep. Results on the impact of wind turbine noise on sleep disburbance, quality of life, and mental health problems differed among cross-sectional studies. There were few studies that addressed the potential impact of turbine noise on clinically apparent health outcomes. There were also few studies on visual risk factors or infrasound exposure. No literature was identified regarding low-frequency noise, electromagnetic radiation, and ice throw. CONCLUSIONS: There is an extensive and diverse body of evidence around health impacts of wind turbines in residential settings, that increased sharply since 2010, showing particularly noise consequences concerning increased noise annoyance with its complex pathways; no relationship between wind turbine noise and stress effects and biophysiological variables of sleep; and heterogeneous findings concerning sleep disturbance, quality of life, as well as mental health problems. Research gaps concern the complex pathways of annoyance, the examination of clinically apparent health outcomes in comparison with non-exposed residents, an objective investigation of visual wind turbine features, the interaction between all wind turbine exposures, and epidemiological observational studies on field low-frequency and infrasound from wind turbines. Future research needs thorough high-quality and prospective study designs.

Variations in experience of social support and physical health among adult residents of Poland in urban versus rural areas

Background: A study reveals ­ against to common beliefs ­less support between rural area residents in comparison to town-dwellers and significantly higher support for healthy, not for poor health research participants. Objectives: The aim of our paper was comparing support from spouse/partner, relatives, friends and strangers among people with good and ill physical health. A next purpose was to find differences of social support and experience of social undermining in urban and rural residential settings. Material and methods: The study "Epidemiology of Mental Disorders and Access to Mental Health Care, EZOP ­ Poland" was carried out on random sample of 24 000 of Poland residents and a 50,4% response rate, 10 081 computerassisted personal interviews. Of those respondents, 4 000 constituted a sub-sample asked to complete the social networks and support section of the questionnaire. Data were analyzed by age, gender, residential setting and marital status for statistically significant differences in the percentage of functional and structural social support being reported, using the chi-squared test with a significance level of 0.05 used to reject the null hypothesis (H0 = lack of relationship between variables). Results: A majority of respondents maintain that in difficult life situations, family and a close network of friends and acquaintances make it possible to openly discuss problems and obtain help. However, respondents who rate their health as "poor" or "very poor" significantly less often than healthy individuals experience support coming from their relatives, friends, or strangers. In comparison to urban areas, the extent of social support in rural areas is significantly limited. The rural setting offers less support and even less opportunities for interaction with relatives, friends, acquaintances and strangers. Negative social factors­ low levels of trust, isolation from friends and family, lack of a social life, lack of a helpful neighborhood ­ are conditions significantly more often found in the countryside than in urban areas. Conclusions: Results obtained from the EZOP study shows that amount of social support received is higher in urban areas and among those who enjoy better physical health.

Homesick: residential and care patterns in patients with severe mental illness.

BACKGROUND: Changes in the residential and care settings of patients with severe mental illness (SMI) are a concern because of the large variety of possible negative consequences. This study describes patterns of changes in the residential and care settings of SMI patients and explores associations between these changes, sociodemographics, and clinical characteristics. METHODS: From January 2006 to January 2012, all data relating to changes in residential and/or care setting by SMI patients (N = 262) were collected from electronic case files. Data covering psychopathology, substance use, and medication adherence were assessed in 2006. RESULTS: There were more changes in the residential than in the care setting. In 6 years, only 22% of our sample did not move, 23% changed residence once, 19% twice, 10% three times, and 26% four or more times. Substance use predicted changes of care and/or residential setting and rehospitalisation. The severity of negative symptoms predicted rehospitalisation and duration of hospitalisation. Disorganisation symptoms predicted the duration of hospitalisation. CONCLUSIONS: A majority of patients with SMI changed residential and/or care settings several times in 6 years. Patients with substance use or severe negative and disorganisation symptoms may need more intensive and customised treatment. Further research is needed to investigate prevention programmes for highly-frequent movers.

Service Availability in Assisted Living and Other Community-Based Residential Settings at the End of Life.

Background: Community-based residential settings (e.g., assisted living facilities and retirement communities), are increasing, where vulnerable older adults are living as they age and die. Despite prevalent serious illness, functional impairment, and dementia among residents, the mix and types of built-in services available are not known. Objective: To classify older adults in community-based residential settings by the types of services available and examine associations between service availability and hospice use and location of death. Design: Pooled cross-sectional analysis. Setting: Medicare Current Beneficiary Survey data (2002-2018). Subjects: U.S. adults 65 years of age and older, who lived in a community-based residential setting and died between 2002 and 2018 (N = 1006). Measurements: Availability (yes/no) of nursing care, medication assistance, meals, laundry, cleaning, transportation, and recreation. Results: Our sample resided in assisted living facilities (32.0%), retirement communities (29.0%), senior citizen housing (13.7%), continuing care facilities (13.5%), and other (11.8%). Four classes of individuals with distinct combinations of available services were identified: 48.2% lived in a residence with all measured services available; 29.1% had availability of all services, except nursing care and medication assistance; 12.6% had availability of only recreation and transportation services; and 10.1% had minimal/no service availability. Of the 51.8% of older adults residing in settings without clinical services, more than half died at home and fewer than half died with hospice. Conclusions: The majority of older adults who die in community-based residential settings do not have access to built-in clinical services. Palliative care training for staff in these settings may be warranted, given variable rates of hospice use and high rates of home death.

Towards the development of a national patient transfer document between residential and acute care-A pilot study.

BACKGROUND: A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document. OBJECTIVES: To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings. METHODS: This was a pre- and post-study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre-pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper-based transfer document was then conducted over three months and post-pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document. RESULTS: Pre-pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person-centred. Post-pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person-centred care but recommended revisions to the new document regarding layout and time to complete. CONCLUSIONS: This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice. IMPLICATIONS FOR PRACTICE: Standardisation and being person-centred are important determining factors in the provision of relevant up to date information on the resident being transferred.

Organizational commitment among residential care workers.

The growth of the older adult population and documented demand of health, allied health, and social care professionals contrast starkly with the reality that the eldercare field, including care organizations, struggle to attract and retain committed workers. Extant studies evaluate organizational capacity to engender commitment by examining various job and workplace factors. Drawing on 44 interviews, observations of 62 meetings, and a 5-year immersion, this organizational ethnography looks at commitment factors at a large, urban, faith-based residential senior care organization. Commitment factors are delineated on three levels such as daily tensions and rewards, value-based tensions and rewards, deal breakers and clinchers. Identity-based factors such as affective bonds with older persons and sharing in faith values sustain commitment on the person level whereas interprofessional tensions may detract from commitment. This study extends the knowledge base by incorporating perspectives of care workers such as social workers, chaplains, rehabilitation, recreational, diet and environmental services workers in addition to the more commonly examined groups such as nurses and certified nursing assistants, and in a setting that includes Assisted Living in addition to long-term care.

Environmental Foundations of Typhoid Fever in the Fijian Residential Setting.

Proximal characteristics and conditions in the residential setting deserve greater attention for their potential to influence typhoid transmission. Using a case-control design in Central Division, Republic of Fiji, we examined bacterial (coliform and Escherichia coli) contamination and chemical composition of water and soil as potential vehicles of exposure to Salmonella Typhi, combining observational analysis of residential living conditions, geospatial analysis of household locations, and factor analysis to explore multivariate associations with the risk of developing typhoid fever. Factors positively associated with typhoid infection related to drainage [phosphate (OR 4.235, p = 0.042) and E. coli concentrations (OR 2.248, p = 0.029) in toilet drainage soil, housing [external condition (OR 3.712, p < 0.001)], drinking water contamination (OR 2.732, p = 0.003) and sanitary condition (OR 1.973, p = 0.031). These five factors explained 42.5% of the cumulative variance and were significant in predicting typhoid infection. Our results support the hypothesis that a combination of spatial and biophysical attributes of the residential setting influence the probability of typhoid transmission; in this study, factors associated with poor drainage, flooding, and sanitary condition increase local exposure to contaminated water and soil, and thereby infection. These findings extend testing of causal assumptions beyond the immediate domestic domain, enhance the scope of traditional case control epidemiology and allow greater specificity of interventions at the scale of the residential setting.

Spatial and temporal variations in the geochemistry of shallow groundwater contaminated with nitrate at a residential site.

The concentrations of nitrate (NO3-), major ions, and dissolved inorganic carbon (DIC) and the stable carbon isotopes of DIC (δ13CDIC) in shallow groundwater below a 45 × 60 m residential property was investigated over a period of 38 months. Our aim was to identify the processes which control the spatial and temporal distribution of NO3- in the shallow groundwater and assess water-rock interactions linked to denitrification. Groundwater sampled quarterly from eight locations showed an average NO3- concentration of 36.8 mg/L and a range between 0.1 and 214.9 mg/L compared to the US EPA maximum contaminant level of 10 mg/L. Heterogeneity in nitrate distribution was from residential application of N-based fertilizers offsite and from onsite application on flower beds and for lawn care. The temporal behavior of nitrate at all eight groundwater locations was markedly different and independent of seasonal hydrologic variations. Nitrate attenuation was spatially controlled by heterogeneous denitrification and rain dilution near roof drains. Groundwater locations with active denitrification were characterized by higher DIC concentrations and lower δ13CDIC from organic carbon mineralization and by higher ionic concentrations from weathering of aquifer minerals. The variation in the relative standard deviations (RSD) of the measured parameters over space (RSD-s) and time (RSD-t) was highest for NO3- associated with variable spatiotemporal input and lowest for pH, pCO2, and δ13CDIC indirectly controlled by denitrification. Denitrification induced mineral weathering products such as DIC, Ca2+, Mg2+, and HCO3- showed medium to high RSD-s and RSD-t. The RSD-s and RSD-t were positively correlated (R2 = 0.85) with the RSD-s showing approximately twofold higher magnitude than RSD-t due to greater variability between monitoring wells locations than variability at each groundwater location over time. Nitrate contamination and denitrification represent important long-term driver of aquifer weathering and changes in groundwater geochemistry below residential communities.

A methodology for generating a tailored implementation blueprint: an exemplar from a youth residential setting.

BACKGROUND: Tailored implementation approaches are touted as more likely to support the integration of evidence-based practices. However, to our knowledge, few methodologies for tailoring implementations exist. This manuscript will apply a model-driven, mixed methods approach to a needs assessment to identify the determinants of practice, and pilot a modified conjoint analysis method to generate an implementation blueprint using a case example of a cognitive behavioral therapy (CBT) implementation in a youth residential center. METHODS: Our proposed methodology contains five steps to address two goals: (1) identify the determinants of practice and (2) select and match implementation strategies to address the identified determinants (focusing on barriers). Participants in the case example included mental health therapists and operations staff in two programs of Wolverine Human Services. For step 1, the needs assessment, they completed surveys (clinician N = 10; operations staff N = 58; other N = 7) and participated in focus groups (clinician N = 15; operations staff N = 38) guided by the domains of the Framework for Diffusion [1]. For step 2, the research team conducted mixed methods analyses following the QUAN + QUAL structure for the purpose of convergence and expansion in a connecting process, revealing 76 unique barriers. Step 3 consisted of a modified conjoint analysis. For step 3a, agency administrators prioritized the identified barriers according to feasibility and importance. For step 3b, strategies were selected from a published compilation and rated for feasibility and likelihood of impacting CBT fidelity. For step 4, sociometric surveys informed implementation team member selection and a meeting was held to identify officers and clarify goals and responsibilities. For step 5, blueprints for each of pre-implementation, implementation, and sustainment phases were generated. RESULTS: Forty-five unique strategies were prioritized across the 5 years and three phases representing all nine categories. CONCLUSIONS: Our novel methodology offers a relatively low burden collaborative approach to generating a plan for implementation that leverages advances in implementation science including measurement, models, strategy compilations, and methods from other fields.

The Use of Biomass for Electricity Generation: A Scoping Review of Health Effects on Humans in Residential and Occupational Settings.

The utilization of biomass for power generation has become more prevalent globally. To survey the status of evidence concerning resulting health impacts and to depict potential research needs, a scoping-review was conducted. Biomass life cycle phases of interest were the conversion and combustion phases. Studies from occupational and residential settings were considered. The scoping review was conducted systematically, comprising an extensive literature search, a guided screening process, in-duplicate data extraction, and critical appraisal. Two reviewers executed most review steps. Nine articles of relevance were identified. In occupational settings of biomass plants, exposure to endotoxins and fungi might be associated with respiratory disorders. An accidental leakage of hydrogen sulfide in biogas plants may lead to fatalities or severe health impacts. Living near biomass power plants (and the accompanied odorous air pollution) may result in an increased risk for several symptoms and odor annoyance, mediated by perception about air pollution or an evaluation of a resulting health risk. The methodological quality of included studies varied a lot. Overall, the body of evidence on the topic is sparse and future high-quality research is strongly recommended.

Effects of declared levels of physical activity on quality of life of individuals with intellectual disabilities.

Routine physical fitness improves health and psychosocial well-being of individuals with intellectual and developmental disabilities. The current study investigated impact of physical fitness on quality of life by comparing individuals who maintain a physically active lifestyle with those who do not report exercising. We assessed several indicators of quality of life, including inclusion and community participation; satisfaction with professional services, home life, and day activities; dignity, rights, and respect received from others; fear; choice and control; and family satisfaction. Our data suggested that individuals who regularly exercise reported having more frequent outings into the community than did their peers who reported exercising infrequently; regular exercisers were also more likely to live in intermediate care facilities (ICF) as opposed to living independently or with family members. We discuss possible reasons for this as well as ideas for future research needed to expand on this area.

The perinatal outcome of children born to women with substance dependence detoxified in residential treatment during pregnancy.

There is growing documentation that infants exposed to opioids and poly-substances prenatally have an increased risk of aberrant development. In Norway, there are several in-patient clinics that specialize in medically supervised detoxification for pregnant women with substance dependence in a therapeutic setting. Because there is virtually no documentation on the perinatal outcome of the infants born to mothers receiving such treatment, this study aims to investigate the perinatal outcome of children born to mothers with opioid and poly-substance dependence detoxified in a residential setting during pregnancy compared with infants born to women with substance dependence at a time when no such treatment was available. Pregnant women from two time cohorts were followed from pregnancy to birth. Birth weight, head circumference, gestational age, and neonatal abstinence syndrome (NAS) were measured in infants born to mothers detoxified in a residential setting during pregnancy and compared with infants born to mothers receiving no treatment. Both study groups had concurrent comparison groups. Infants born to mothers in residential detoxification treatment experience less prenatal drug exposure and show better perinatal outcomes on gestational age and head circumference, as well as no NAS, compared to the infants in the earlier cohort whose mothers did not receive residential treatment. No miscarriages, complications, or morbidities were associated with residential detoxification treatment. Detoxification in residential treatment can be a preferred treatment form for many pregnant women struggling with drug abuse problems and should possibly be applied to a larger extent to ensure the best possible perinatal outcome for these children.