Boone Hospital Center

IMPORTANCE: Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease. OBJECTIVE: To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection. INTERVENTIONS: Standard laparoscopic and open approaches were performed by the credentialed surgeons. MAIN OUTCOMES AND MEASURES: The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation. RESULTS: Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91). CONCLUSIONS AND RELEVANCE: Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00726622.

PURPOSE: To evaluate the efficacy of a 6-month course of responsivity education/prelinguistic milieu teaching (RE/PMT) for children with developmental delay and RE/PMT's effects on parenting stress in a randomized clinical trial. METHOD: Fifty-one children, age 24-33 months, with no more than 10 expressive words or signs, were randomly assigned to treatment/no-treatment groups. Thirteen children in each group had a diagnosis of Down syndrome. RESULTS: In 1 of 2 multivariate comparisons, the RE/PMT group exhibited superior gains in communication compared with the no-treatment group. The treatment effect for overall use of intentional communication acts in the child-examiner context was significant (d = .68, 95% confidence interval = 0.12-1.24). There were no effects on child outcomes due to presence or absence of Down syndrome. RE/PMT led to modest increases in recoding of child acts by parents of children who did not have Down syndrome. There were no effects on parenting stress associated with the intervention or the presence or absence of Down syndrome. CONCLUSIONS: RE/PMT may be applied clinically with the expectation of medium-size effects on the child's rate of intentional communication acts after 6 months of intervention. The approach warrants further investigation with modifications, such as delivery at higher intensity levels.

BACKGROUND: Adolescence is the period of most rapid growth second to childhood. The physical and physiological changes that occur in adolescents place a great demand on their nutritional requirements and make them more vulnerable to anemia. Anemia in the adolescence causes reduced physical and mental capacity and diminished concentration in work and educational performance, and also poses a major threat to future safe motherhood in girls. The purpose of this study was to determine the prevalence of anemia and its associated factors among school adolescents in Bonga Town, southwest Ethiopia. METHODS: A cross-sectional study was conducted among 408 school adolescents in Bonga Town, southwest Ethiopia, from March 15, 2014 to May 25, 2014. An interviewer-administered questionnaire was used to collect sociodemographic and other data. A total of 7 mL of venous blood and 4 g of stool samples were collected from each study participant. Blood and stool samples were analyzed for hematological and parasitological analyses, respectively. Data were analyzed using SPSS Version 20 software for Windows. RESULTS: The overall prevalence of anemia was 15.2% (62/408), of which 83.9% comprised mild anemia. The proportion of microcytic, hypochromic anemia was 53% (33/62). Being female (adjusted odds ratio [AOR] =3.04, 95% confidence interval (CI) =1.41-6.57), household size ≥5 (AOR =2.58, 95% CI =1.11-5.96), father's illiteracy (AOR =9.03, 95% CI =4.29-18.87), intestinal parasitic infection (AOR =5.37, 95% CI =2.65-10.87), and low body mass index (AOR =2.54, 95% CI =1.17-5.51) were identified as determinants of anemia among school adolescents. CONCLUSION: This study showed that anemia was a mild public health problem in this population. School-based interventions on identified associated factors are important to reduce the burden of anemia among school adolescents.

OBJECTIVES: This study examined whether pretreatment self-efficacy and pre- to post-treatment changes in self-efficacy predict post-treatment tender point index, disease severity, pain, and physical activity. METHODS: One hundred nine subjects with fibromyalgia were assessed before and after a 6-week training intervention. Measures included tender point index, physician ratings of disease severity, the visual analog scale for pain, the Physical Activities subscale of the Arthritis Impact Measurement Scales, and the Arthritis Self-Efficacy Scale. RESULTS: Pretreatment self-efficacy significantly predicted post-treatment physical activity, with higher self-efficacy associated with better physical activity outcome. Changes in self-efficacy significantly predicted post-treatment tender point index, disease severity, and pain; improvements in self-efficacy were associated with better outcomes on each measure. CONCLUSIONS: Higher levels of self-efficacy are associated with better outcome, and may mediate the effectiveness of rehabilitation-based treatment programs for fibromyalgia.

REASONS FOR PERFORMING STUDY: Critical illness is associated with hyperglycemia in humans, and a greater degree and duration of hyperglycemia is associated with nonsurvival. Hypoglycemia is also seen in critically ill humans, and is associated with nonsurvival. This might also be true in the critically ill foal. OBJECTIVES: To investigate the association of blood glucose concentrations with survival, sepsis, and the systemic inflammatory response syndrome (SIRS). METHODS: Blood glucose concentrations at admission (515 foals) and 24 hours (159 foals), 36 hours (95), 48 hours (82), and 60 hours (45) after admission were analyzed. Logistic regression analyses were performed to investigate the association of glucose concentrations with survival, sepsis, a positive blood culture, or SIRS. RESULTS: 29.1% of foals had blood glucose concentrations within the reference range (76-131 mg/dL) at admission, 36.5% were hyperglycemic, and 34.4% were hypoglycaemic. Foals that did not survive to hospital discharge had lower mean blood glucose concentrations at admission, as well as higher maximum and lower minimum blood glucose concentrations in the 1st 24 hours of hospitalization, and higher blood glucose at 24 and 36 hours. Foals with blood glucose concentrations <2.8 mmol/L (50 mg/dL) or >10 mmol/L (180 mg/dL) at admission were less likely to survive. Hypoglycemia at admission was associated with sepsis, a positive blood culture, and SIRS. CONCLUSIONS AND POTENTIAL RELEVANCE: Derangements of blood glucose concentration are common in critically ill foals. Controlling blood glucose concentrations may therefore be beneficial in the critically ill neonatal foal, and this warrants further investigation.

Background Programs such as Medicaid Home and Community-based Services (HCBS) have provided an alternative to institutionalization through community-based, long-term care services; however, there are limited studies on the clinical outcomes of participants in these programs as compared to nursing home (NH) residents. Objective To compare clinical outcomes of individuals in a community-based, long-term care program to individuals of similar case mix in institutional-based, long-term care. Methods A program called Aging in Place (AIP) was developed by the Sinclair School of Nursing in cooperation with the state of Missouri's HCBS program. The AIP intervention consisted of nurse coordination of the HCBS program and Medicare home health services. A total of 78 AIP participants were matched with 78 NH residents on admission period, activities of daily living (ADLs), cognitive status, and age. The Minimum Data Set (MDS) was collected on the AIP group at admission and every 6 months over a 30-month period. Cognition was measured by the MDS Cognitive Performance Scale (CPS), ADLs by the sum of 5 MDS ADL items, depression by the MDS-Depression Rating Scale, and incontinence by rating on 2 MDS items related to urinary continence. The Cochran–Mantel–Haenszel method was used to test the association between the AIP intervention and clinical outcomes. Results The AIP group clinical outcomes were better at a statistically significant level (less than .05) for the following outcomes: (a) cognition at 6, 12, and 18 months (p = .00); (b) depression at 6 and 12 months (p = .00); (c) ADL at 6 (p = .02), 12 (p = .04), and 24 (p = .00) months; and (d) incontinence at 24 (p = .02) months. In all 4 outcome measures, the AIP group stabilized or improved outcome scores whereas the NH group's outcome scores deteriorated. Discussion Study results suggest that community-based care with nurse coordination enhances clinical outcomes of long-term care participants.

Laparoscopic techniques have recently been extended to the performance of segmental colon resections. We report two cases in which laparoscopic techniques were used to perform total proctocolectomy with ileostomy for patients with severe ulcerative colitis. Our experience encourages us that laparoscopic surgery will also prove to be of benefit for this subset of patients.

Laparoscopic surgical techniques have recently been applied to various types of colon resection. Early reports have focused on the technical feasibility of these procedures, and it has not yet been clearly shown that such procedures benefit the patient. We reviewed our experience with 28 attempted minimally invasive colectomies (MICs) performed over a nine-month period. Laparoscopic or laparoscopic-assisted resections were successfully completed in 24 of these patients. We compared the results of surgery in these 24 patients with a group of 33 patients undergoing similar procedures at the same institution by the same surgeon in the nine months preceding the laparoscopic experience. The two groups of patients were similar with respect to age, weight, and the types of procedures performed. However, the postoperative length of stay for patients undergoing MIC (4.8 days) was significantly shorter than for those undergoing open colectomies (8.2 days). Patients undergoing MIC also regained bowel function significantly earlier than those undergoing open colectomy. The operative times for the minimally invasive procedures were significantly longer than for those undergoing open colectomy. No surgically related deaths were encountered, and morbidity was 13 percent. None of the four patients converted from laparoscopic to open colectomy suffered complications as a result of the attempted laparoscopic procedure. We conclude that MIC can be safely performed and does appear to reduce the duration of postoperative ileus and decrease the length of postoperative hospitalization.

OBJECTIVES: The FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH) is a prospective multi-center registry evaluating the safety and effectiveness of percutaneous mechanical thrombectomy for treatment of pulmonary embolism (PE) in a real-world patient population (NCT03761173). This interim analysis reports outcomes for the first 250 patients enrolled in FLASH. BACKGROUND: High- and intermediate-risk PEs are characterized by high mortality rates, frequent readmissions, and long-term sequelae. Mechanical thrombectomy is emerging as a front-line therapy for PE that enables immediate thrombus reduction while avoiding the bleeding risks inherent with thrombolytics. METHODS: The primary endpoint is a composite of major adverse events (MAE) including device-related death, major bleeding, and intraprocedural device- or procedure-related adverse events at 48 h. Secondary endpoints include on-table changes in hemodynamics and longer-term measures including dyspnea, heart rate, and cardiac function. RESULTS: Patients were predominantly intermediate-risk per ESC guidelines (6.8% high-risk, 93.2% intermediate-risk). There were three MAEs (1.2%), all of which were major bleeds that resolved without sequelae, with no device-related injuries, clinical deteriorations, or deaths at 48 h. All-cause mortality was 0.4% at 30 days, with a single death that was unrelated to PE. Significant on-table improvements in hemodynamics were noted, including an average reduction in mean pulmonary artery pressure of 7.1 mmHg (22.2%, p < 0.001). Patient symptoms and cardiac function improved through follow-up. CONCLUSIONS: These interim results provide preliminary evidence of excellent safety in a real-world PE population. Reported outcomes suggest that mechanical thrombectomy can result in immediate hemodynamic improvements, symptom reduction, and cardiac function recovery.

Abstract The authors propose a model of cultural trauma and revitalization. The theory suggests a framework for understanding disruptions that an "original" culture might suffer at the imposition of an "arriving" culture resulting in vulnerabilities of individuals, families/small groups, communities, and the larger societies. The cultural clash model posits that original cultures have identifiable and sustainable economic, social, political, and spiritual systems in the pre-contact era. Exposure to an arriving culture can radically alter the character and sustainability of the original culture. Emergence from the challenge can lead to cultural dissolution, but there can also be revitalization and reorganization. This can occur if the injured culture lays claim to economic and social resources, preferably with the support and encouragement of the hegemonic culture. The end result can be a form of bicultural or multicultural adaptation by the members of the original culture. Suggestions for testing the model of cultural trauma are offered by using culturally relevant variables in path analysis or structural equation modeling. The article closes with a discussion of issues related to individual, small group, community, and societal interventions following cultural loss and trauma. The opinions or assertions contained herein are the private ones of the authors, and are not to be considered as official or reflecting the views of the author' institutions. We wish to recognize with gratitude the contributions over the years of our colleagues on the Project for Community Revitalization & Healing of Cultural Trauma (www.isu.edu/∼bhstamm) and others who have contributed to the concepts underlying this article, including Maxim Dolchok, Lisa Dolchock, Robert Morgan, Laurie Anne Pearlman, Ervin Staub, Stan Cudek, James Trosper, Bushra Hassan, Livia Iskandar-Dharmawan, David Samolu, Randolph A. West, Peter Petschauer, Antoly Isaenko, and Martin Seligman. Notes 1These terms are less than ideal, but are used to describe the most generalizable form of the relationship. A recognizable form of this cultural interchange is colonialism, although there are other examples such as conflict between divergent groups of one culture, or when enclaves of refugees must deal with their host country's culture. Additional informationNotes on contributorsB. HUDNALL STAMM B. Hudnall Stamm, Ph.D., is a Research Professor and Director of Telehealth at the Idaho State University Institute of Rural Health. Working primarily with rural and underserved peoples, Dr. Stamm focuses on cultural trauma, telehealth, and secondary traumatic stress. See www.isu.edu/∼bhstamm and www.isu.edu/irh for more information. HENRY E. STAMM Henry E. Stamm, IV, Ph.D., is a historian at the Wind River History Center, Dubois Wyoming with special research focus on the history of the Eastern Shoshones. His published works include People of the Wind River and multiple articles. He has also appeared on documentary films on the region. see www.windriverhistory.org for more information. AMY C. HUDNALL Amy C. Hudnall, M.A., is an Adjunct Professor in the History Department at Appalachian State University. Her work focuses on cross-cultural trauma and genocide from an historical frame of reference. She is also the managing editor for the NWSA Journal, the flagship journal of the National Women's Studies Association. CRAIG HIGSON-SMITH Craig Higson-Smith, M.A., is a South African research Senior Research Specialist in the Human Sciences Research Council of South AFrica, a director of the South African Institute for Traumatic Stress, and works as a private consultant to various South African industries. His specialist interests are in the fields of violence, traumatic stress, and community psychology.

ABSTRACT Newly established early Cenozoic fossil localities within the “coastal belt” of Franciscan rocks recall the furor which developed before the last decade over occurrences of Cretaceous fossils within the Franciscan “Formation” of presumably Late Jurassic age. It is timely to consider again the question—what is Franciscan?—not only in regard to what physically constitutes the Franciscan, but also to what it should be called. The Franciscan is herein designated a complex, and is defined as the folded, faulted, and stratally disrupted basement terrane of the California Coast Ranges—including extensions into Oregon and Mexico—which is composed of graywacke, shale, minor conglomerate, radiolarian chert and siliceous shale, minor limestone, volcanic rocks, mafic-ultramafic plutonic rocks, and their zeolite-to-blueschist-facies metamorphic equivalents. Thus, the Franciscan Complex is shown to have both structural and lithologic significance. Other terms used in connection with Franciscan rocks are also defined.

Abstract Aim To evaluate the long-term outcome of patients with Takotsubo syndrome (TTS) and severely reduced left ventricular ejection fraction (LVEF ≤ 35%) at presentation. Methods and results The study population included 326 patients (mean age 69.5 ± 10.7 years, 28 male) with TTS enrolled in the Takotsubo Italian Network, divided into two groups according to LVEF (≤ 35%, n = 131; &amp;gt; 35%, n = 195), as assessed by transthoracic echocardiography at hospital admission. In-hospital events were recorded in both groups. At long-term follow-up (median 26.5 months, interquartile range 18–33), composite major adverse cardiac events (MACE: cardiac death, acute myocardial infarction, heart failure, and TTS recurrence) and rehospitalization were investigated. Compared to patients with LVEF &amp;gt; 35%, patients with LVEF ≤ 35% were older (71.2 ± 10.8 vs. 68.4 ± 10.6 years; P = 0.026) and experienced more frequently cardiogenic shock (16% vs. 4.6%; P &amp;lt; 0.001), acute heart failure (28.2% vs. 12.8%; P = 0.001), and intra-aortic balloon pump support (11.5% vs. 2.6%; P = 0.001) in the acute phase. At long-term follow-up, higher rates of composite MACE (25.2% vs. 10.8%; P = 0.001) and rehospitalization for cardiac causes (26% vs. 13.3%; P = 0.004) were observed in these patients. LVEF ≤ 35% at admission [hazard ratio (HR) 2.184, 95% confidence interval (CI) 1.231–3.872; P = 0.008] and age (HR 1.041, 95% CI 1.011–1.073; P = 0.006) were independent predictors of MACE. Patients with LVEF ≤ 35% also had a significant lower freedom from composite MACE during long-term follow-up (χ2 = 11.551, P = 0.001). Conclusion Left ventricular ejection fraction ≤ 35% at presentation is a key parameter to identify TTS patients at higher risk not only in the acute phase but also at long-term follow-up.

INTRODUCTION: Ipilimumab, a monoclonal anti-CTLA-4 antibody, is used to treat melanoma. Neuromuscular side effects, possibly autoimmune, may occur. METHODS: In this investigation we undertook a retrospective review of patient records. RESULTS: After 3 doses of ipilimumab, a 31-year-old man developed asymmetric, severe weakness involving all limbs, respiration, and cranial nerves, which was progressive over 2 weeks. EMG/NCS showed an axonal polyradiculoneuropathy with multifocal motor conduction blocks. CSF protein was 749 mg/dl. Nerve pathology showed inflammation around the endoneurial microvessels and subperineurial edema and inflammation. Spine MRI showed leptomeningeal and anterior and posterior root enhancement. Strength improved slowly over months after ipilimumab discontinuation and immunomodulating treatment. CONCLUSIONS: Ipilimumab toxicity presented as a monophasic, multifocal, asymmetric polyradiculoneuropathy involving roots and peripheral and cranial nerves. Ipilimumab may produce a polyradiculoneuropathy with disruption of the blood-nerve barrier due to a microvasculopathy.

ABSTRACT Canadian and Japanese barleys were compared for whole and pearled grain composition and starch properties. Whole grain color and composition of the barleys showed large intercultivar differences, but few (color, protein, and total dietary fiber) significant differences between the Canadian and Japanese barleys. The Canadian hull‐less barleys (HB) were pearled to 55% yield to match pearl yields of Japanese barleys. In Canadian HB, pearl time was correlated ( r 2 = +0.96**) with grain hardness. There were large intercultivar differences in color and composition of the pearled barleys; only protein, starch, total dietary fiber, and viscosity showed significant differences between the Canadian and Japanese pearled barleys. Pasting properties of the four Canadian pearled barleys (CDC Candle, AC Hawkeye, Falcon, and CDC Richard) and three Japanese pearled barleys (Hinode, Ichiban‐Boshi, and Minori) showed Canadian pearled barleys had higher peak viscosity, viscosity at 95°C, and setback viscosity than the Japanese barleys. These differences in pasting properties were not related to amylose or crude lipid contents of Canadian and Japanese pearled barleys, nor to swelling factor and thermal properties of starches isolated from the barleys. They were likely due to higher β‐glucan and protein in starch slurries of Canadian HB.

METHODS: In an open randomized study we compared the safety and immunogenicity of two schedules for priming and booster vaccinations of infants. A pentavalent combination vaccine, including a lyophilized Haemophilus influenzae type b-tetanus toxoid conjugate vaccine reconstituted with a liquid diphtheria, tetanus, acellular pertussis (pertussis toxoid and filamentous hemagglutinin) and inactivated polio vaccine (DTaP-IPV/Act-HIB; Pasteur Mérieux Connaught, Lyon, France) was administered to 236 Swedish infants either at 2, 4 and 6 months or at 3 and 5 months, and a booster dose was administered 7 months after the last primary dose. Adverse events were monitored by diaries for 3 days after each vaccination and by questions at the ensuing visits. Antibodies against the different vaccine components were analyzed after the primary series of vaccinations, before and after the booster injections. RESULTS: There were no serious adverse reactions, and the rates of febrile events and local reactions were low in both groups. The three dose primary schedule induced higher geometricmean concentrations for all antigens than did the two dose schedule, but there were no differences between the groups in proportions with protective antibody titers against diphtheria, tetanus, Hib and polio or in proportions with certain defined levels of pertussis antibodies. Prebooster results showed a similar pattern, with the exception that the group primed with three injections showed higher proportions of infants with detectable antibodies against polio-virus types 1 and 3. After booster vaccinations there were no differences between the two schedules in geometric mean or in proportions with antibodies above defined antibody concentrations, indicating effective priming from both primary series of vaccinations. Conclusion. The combined vaccine DTaP-IPV/ Act-HIB vaccine was equally safe and immunogenic when administered according to both time schedules studied.

Systemic lupus erythematosus (SLE), a chronic autoimmune illness, is influenced by hormones. High prolactin concentrations were associated with early death from autoimmune renal disease in NZB/NZW mice, an animal model of severe SLE. NZB/NZW mice that delivered and nursed pups and those that underwent pseudopregnancy had changes in serum IgG and autoantibodies. NZB/NZW mice treated with the prolactin-suppressing drug bromocriptine had prolonged lives. Elevated serum prolactin concentrations are reported in SLE patients of both sexes. We found four women with long-standing hyper-prolactinemia who developed SLE. A survey of premenopausal women whose sera were submitted for autoantibody testing showed that 20% with anti-ds-DNA antibodies also had high prolactin levels. Many hyperprolactinemic patients whose sera were referred to an endocrinology laboratory had positive FANA tests (women 33%, men 53%) but did not have SLE. Disease activity was suppressed in six of seven SLE patients treated with bromocriptine. All had elevated disease activity and five became unexpectedly hyperprolactinemic after treatment stopped. Manipulating serum prolactin affords a means of treating clinical SLE activity.

Endometriosis is a complex and common gynecological disorder yet a poorly understood disease affecting about 176 million women worldwide, and causing significant impact on their quality of life and economic burden. Neither a definitive clinical symptom nor a minimally invasive diagnostic method is available thus leading to an average of 10 years of diagnostic latency. Discovery of relevant biological patterns from microarray expression or next generation sequencing (NGS) data has been advanced over the last several decades by applying various machine learning tools. We performed machine learning analysis using 38 RNA-seq and 80 enrichment-based DNA-methylation (MBD-seq) datasets. We experimented how well various supervised machine learning methods such as decision tree, partial least squares discriminant analysis (PLSDA), support vector machine and random forest perform in classifying endometriosis from the control samples trained on both transcriptomics and methylomics data. The assessment was done from two different perspectives for improving classification performances: (a) implication of three different normalization techniques, and (b) implication of differential analysis using the generalized linear model (GLM). Several candidate biomarker genes were identified by multiple machine learning experiments including NOTCH3, SNAPC2, B4GALNT1, SMAP2, DDB2, GTF3C5, and PTOV1 from the transcriptomics data analysis, and TRPM6, RASSF2, TNIP2, RP3-522J7.6, FGD3, and MFSD14B from the methylomics data analysis. We concluded that an appropriate machine learning diagnostic pipeline for endometriosis should use TMM normalization for transcriptomics data, and quantile or voom normalization for methylomics data, GLM for feature space reduction and classification performance maximization.

PURPOSE: To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). DESIGN: A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. METHODS: Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. FINDINGS: At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. CONCLUSIONS: Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

1. Exercise is important and recommended for older adults. Nurses in community settings are in ideal positions to facilitate older adults' use of exercise programs. 2. Quality of life is complex and multidimensional. Dimensions include well-being, functional status, socioeconomic status, and self-esteem. 3. This article contains a review of empirical evidence that states older adults who exercise have improved quality of life.

Abstract A versatile, simulation‐based framework for risk assessment and probabilistic sensitivity analysis of base‐isolated structures is discussed in this work. A probabilistic foundation is used to address the various sources of uncertainties, either excitation or structural, and to characterize seismic risk. This risk is given, in this stochastic setting, by some statistics of the system response over the adopted probability models and stochastic simulation is implemented for its evaluation. An efficient, sampling‐based approach is also introduced for establishing a probabilistic sensitivity analysis to identify the importance of each of the uncertain model parameters in affecting the overall risk. This framework facilitates use of complex models for the structural system and the excitation. The adopted structural model explicitly addresses nonlinear characteristics of the isolators and of any supplemental dampers, and the effect of seismic pounding of the base to the surrounding retaining walls. An efficient stochastic ground motion model is also discussed for characterizing future near‐fault ground motions and relating them to the seismic hazard for the structural site. An illustrative example is presented that emphasizes the results from the novel probabilistic sensitivity analysis and their dependence on seismic pounding occurrences and on addition of supplemental dampers. Copyright © 2011 John Wiley &amp; Sons, Ltd.