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Background. Weight-bearing exercise has been discouraged for people with diabetes mellitus and peripheral neuropathy (DM + PN). However, people with diabetes mellitus and insensate feet have an increased risk of falling. Lower-extremity exercise and balance training reduce fall risk in some older adults. It is unknown whether those with neuropathy experience similar benefits. Objective. As part of a study of the effects of weight-bearing exercise on foot ulceration in people with DM+PN, the effects of a lower-extremity exercise and walking intervention on balance, lower-extremity strength (force-generating capacity), and fall incidence were determined. Design. The study was an observer-masked, 12-month randomized controlled trial. Setting. Part I of the intervention took place in physical therapy offices, and part 2 took place in the community. Patients. The participants were 79 people who were mostly sedentary, who had DM + PN, and who were randomly assigned to either a control group (n = 38) or an intervention group (n = 41). Intervention. Part I included leg strengthening and balance exercises and a graduated, self-monitored walking program; part 2 included motivational telephone calls. Both groups received regular foot care, foot care education, and 8 sessions with a physical therapist. Measurements. The measurements collected were strength, balance, and participant-reported falls for the year after enrollment. Results. There were no statistically significant differences between the groups for falls during follow-up. At 12 months, there was a small increase in the amount of time that participants in the intervention group could stand on 1 leg with their eyes closed. No other strength or balance measurements differed between the groups. Limitations. The study was designed to detect differences in physical activity, not falls. The intensity of the intervention was insufficient to improve strength and balance in this population. Conclusions. The training program had a minimal effect on participants balance and lower-extremity strength. Increasing weight-bearing activity did not alter the rate of falling for participants in the intervention group relative to that for participants in the control group. People who are sedentary and who have DM + PN appear to be able to increase activity without increasing their rate of falling. [ABSTRACT FROM AUTHOR]

Background: Weight-bearing exercise has been contraindicated among people with diabetic peripheral neuropathy (DM+PN). However, recent cohort studies have suggested that daily weight-bearing activity is associated with lower risk for foot ulceration.Objective: The objective of this study was to determine the effect of a lower-extremity exercise and walking intervention program on weight-bearing activity and foot ulcer incidence in people with DM+PN.Design: This was an observer-blinded, 12-month randomized controlled trial.Setting: The settings were physical therapy offices in part 1 of the intervention and the community in part 2 of the intervention.Participants: The participants were 79 individuals with DM+PN who were randomly assigned either to a control group (n=38) or an intervention group (n=41) group.Intervention: Intervention components included leg strengthening and balance exercises; a graduated, self-monitored walking program (part 1); and motivational telephone calls every 2 weeks (part 2). Both groups received diabetic foot care education, regular foot care, and 8 sessions with a physical therapist.Measurements: Total and exercise boutDSrelated daily steps at baseline and at 3, 6, and 12 months were measured by accelerometers. Foot lesions/ulcers were photographed and classified by an independent panel of dermatologists. Use of adequate footwear was monitored.Results: At 6 months, bout-related daily steps increased 14% from baseline in the intervention group and decreased 6% from baseline in the control group. Although the groups did not differ statistically in the change in total daily steps, at 12 months steps had decreased by 13% in the control group. Foot ulcer rates did not differ significantly between groups.Conclusion: Promoting weight-bearing activity did not lead to significant increases in foot ulcers. Weight-bearing activity can be considered following adequate assessment and counseling of patients with DM+PN. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997.Data Sources: We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics.Study Design: Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics.Principal Findings: There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased.Conclusions: The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use. [ABSTRACT FROM AUTHOR]

In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their 'more altruistic' mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publically reported health safety deficiency scores documented during standard inspections., Methods: The sample included 807 NHs from every U.S. state. A total of 2187 health inspections were documented in these facilities. A national IT sophistication survey describing IT capabilities, extent of IT use, and degree of IT integration in resident care, clinical support, and administrative activities in U.S. NHs was used. The relationship between NH health deficiencies and IT sophistication survey scores was examined, using weighted regression., Results: Controlling for registered nurse hours per resident day, deficiency scores decreased as total IT sophistication increased. Controlling for total IT sophistication score, deficiency scores decreased as registered nurse hours per resident day increased. Ownership status significantly influenced health deficiency scores., Conclusions: These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ 2 [5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.]., (Copyright 2019, SLACK Incorporated.)

Objective: To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location., Methods: We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons., Principal Findings: Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas., Conclusions: This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined., (© 2016 National Rural Health Association.)

Objective: To provide a report on year 1 results of a national study investigating nursing home information technology (IT) adoption, called IT sophistication., Methods: A reliable and valid survey was used to measure IT sophistication. The target goal was 10% from each state in the United States, 1570 nursing homes. A random sample of homes from each state was recruited from Nursing Home Compare., Results: The team reached 2627 nursing home administrators, among whom 1799 administrators agreed to participate and were sent a survey. A total of 815 surveys were completed (45.3% response rate), which was below the goal. Facilities in the participating sample have similar demographic characteristics (ownership, total population in a location, and bed size) to the remaining homes not participating. There are greater IT capabilities in resident care and administrative activities, less in clinical support. The extent of use of these capabilities appears to be highest in administrative activities and lowest in clinical support. IT in resident care appears to be the most integrated with internal and external stakeholders. IT capabilities appear to be greater than IT extent of use in all health domains, with the greatest difference in resident care., Discussion: National evaluations of nursing home IT are rare. Measuring trends in IT adoption in a nationally representative sample provides meaningful analytics that could be more useful for policy makers and nursing home leaders in the future., Conclusion: Discovering national baseline assessments is a first step toward recognizing nursing home trends in IT adoption., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: To determine the clinical effectiveness and potential neuroprotection of levodopa in improving visual acuity, visual field, and retinal nerve fiber layer (RNFL) thickness in eyes affected by NAION., Method: Retrospective cohort study involving 59 eyes of 59 participants with NAION who were evaluated within 15 days of NAION onset. Participants received 25 mg carbidopa/100 mg levodopa three times daily with meals for 12 weeks (levodopa group) or were untreated (control group). Best-corrected visual acuity converted to logMAR, mean deviation (MD) threshold sensitivity on automated perimetry, and mean RNFL thickness on optical coherence tomography (OCT) were assessed. The primary outcome was the categorization of eyes into improved visual acuity (by 0.3 logMAR difference), worsened visual acuity (by 0.3 logMAR difference), or no change in visual acuity. The proportions in each category were compared between the levodopa and control groups., Results: Among participants with 20/60 or worse initial visual acuity, levodopa-treated participants had significant improvement (P < 0.0001) in the mean change from initial to final logMAR visual acuity of -0.74 ± 0.56 (95 % CI, -0.98 to -0.50), while the mean change for the control group at -0.37 ± 1.09 (95 % confidence interval estimate, -1.00 to +0.26) was not significant (P = 0.23). A significant difference between groups was observed (P = 0.0086) such that 19/23 (83 %) in the levodopa group improved and none got worse, as compared with 6/14 (43 %) in the control group improving while four (29 %) worsened. The change in visual field MD and RNFL thickness on OCT showed no significant difference at P = 0.23 and P = 0.75 respectively. No levodopa-treated participant had any adverse event from the levodopa., Conclusions: Treatment within 15 days of onset of NAION with levodopa improved central visual acuity by an average of 6 lines on Snellen acuity chart. Levodopa may promote neuroprotection of the maculopapular retinal ganglion cell fibers in NAION.

Vaccinations reduce the risk of hospitalizations and adverse health outcomes in older adult populations, which has led to initiatives such as the Healthy People 2010 goal to vaccinate 90% of all nursing home residents. The current analysis looked at the percentage of residents who received vaccinations in 15,653 nursing homes in the United States and relationships of vaccination to staffing intensity and regional location. Overall, approximately 75% of facilities reached the optimum 90% vaccination levels for long-term residents, but less than 50% reached this goal for short-term residents. Further analyses revealed a consistently lower median rate of vaccination for metropolitan areas and indicated a weak relationship between staffing levels of RNs and short-term resident vaccination. Factors influencing staffing levels, and the possible connection between vaccination and technology, are discussed, as well as suggestions for future research aimed at better understanding mechanisms involved in suboptimal influenza and pneumococcal vaccination in nursing homes. [Journal of Gerontological Nursing, 42(2), 38-44.]., (Copyright 2016, SLACK Incorporated.)

Objective: To determine the effect of repeated gas sterilization on rate of closure of ameroid ring constrictors in vitro., Sample: Twenty-four 3.5-mm ameroid ring constrictors., Procedures: Ameroid ring constrictors were allocated to 1 of 4 treatment groups (6/group) to undergo gas sterilization 0, 1, 5, or 10 times. After sterilization, constrictors were incubated in canine plasma at a protein concentration of 3 g/dL for 27 days. A digital camera was used to obtain images of the constrictors prior to and at various points during incubation, and lumen diameter was measured., Results: Mean ± SD percentage of lumen closure for all groups of ameroid ring constrictors combined was 85.2 ± 1.6% at day 0 (prior to plasma incubation) and 95.4 ± 0.8% at day 27. Mean lumen area was 3.64 ± 0.43 mm(2) (95% confidence interval, 2.67 to 4.77 mm(2)) at day 0 and 1.32 ± 0.25 mm(2) (95% confidence interval, 0.76 to 2.04 mm(2)) at day 27. None of the ameroid ring constrictors had closed completely by day 27., Conclusions and Clinical Relevance: Overall closure rates for ameroid ring constrictors appeared to be unaffected by repeated gas sterilization up to 10 times. Findings suggested that veterinary surgeons can resterilize ameroid ring constrictors up to 10 times with confidence that ring properties would remain suitable for clinical use.

Objective: To investigate long-term outcomes and owner-perceived quality of life associated with sudden acquired retinal degeneration syndrome (SARDS) in dogs., Design: Survey study., Animals: 100 dogs with SARDS examined at 5 academic veterinary institutions from 2005 to 2010., Procedures: The diagnosis was based on documented acute vision loss, normal results of ophthalmic examinations, and evaluation of extinguished bright-flash electroretinograms. Primary owners of affected dogs completed a questionnaire addressing outcome measures including vision, systemic signs, and perceived quality of life for their dogs., Results: Age at diagnosis was significantly correlated with positive outcome measures; dogs in which SARDS was diagnosed at a younger age were more likely to have alleged partial vision and higher owner-perceived quality of life. Polyphagia was the only associated systemic sign found to increase in severity over time. Medical treatment was attempted in 22% of dogs; visual improvement was not detected in any. Thirty-seven percent of respondents reported an improved relationship with their dog after diagnosis, and 95% indicated they would discourage euthanasia of dogs with SARDS., Conclusions and Clinical Relevance: Blindness and concurrent systemic signs associated with SARDS appeared to persist indefinitely, but only polyphagia increased in severity over time. Most owners believed their pets had good quality of life and would discourage euthanasia of dogs with SARDS.

The objective of this study was to compare two portable lactate analyzers for testing canine patients in a clinical setting with a previously accepted methodology for measuring plasma lactate. Between Jan 1, 2005 and Jun 1, 2006, all samples were analyzed using two different portable analyzers (devices A and B), and 86 of those samples were also analyzed by a reference laboratory (REF). The concordance correlation coefficient (CCC) for device A and the REF was 0.949 (95% confidence interval [95% CI], 0.923-0.966). For device B and REF, the CCC was 0.990 (95% CI, 0.985-0.993). Only 8 of 85 samples (9.4%) exceeded a relative difference of 20% for device B (note that 1 of the 86 samples was not included because the lactate level fell below the detectable limit of device B), but 48 of 85 samples (56.5%) exceeded a relative difference of 20% for device A. Both portable lactate analyzers appeared to be effective in detecting clinically significant elevations in plasma lactate compared with the REF but device B had better agreement. A positive correlation among all three analyzers existed; however, the analyzers do not yield directly interchangeable results.

Purpose: To compare the changes in retinal nerve fiber layer (RNFL) thickness and optic nerve cup/disc ratio on optical coherence tomography (OCT) between users and nonusers of inhaled and intranasal corticosteroids (ICS)., Methods: Retrospective study of participants with glaucoma or glaucoma suspect having 2 or more OCTs during a 6-year period. The rates of change in Stratus OCT fast RNFL thickness scan and fast optic disc scan data were compared between ICS users and nonuser controls using random coefficient models., Results: A total of 170 participants met the inclusion criteria, of whom 42 (25%) were ICS users and 128 (75%) were controls. The mean duration of follow-up was 3.2 years. There were no significant differences in the mean rates of change in superior RNFL (-0.8874 µm/y ICS users; -0.8592 µm/y controls; p=0.943), nasal RNFL (-0.0529 µm/y ICS users; -0.3577 µm/y controls; p=0.419), inferior RNFL (0.2703 µm/y ICS users; -0.1910 µm/y controls; p=0.165), and temporal RNFL (-0.3618 µm/y ICS users; -0.3612 µm/y controls; p=0.998) between ICS users and controls. There were no significant differences in the mean rates of change in horizontal cup/disc ratio (-0.0047 µm/y ICS users; 0.0002 µm/y controls; p=0.212) and vertical cup/disc ratio (0.0013 µm/y ICS users; 0.0029 µm/y; p=0.717) between ICS users and controls., Conclusions: We found no significant difference in the rates of RNFL or optic nerve cup/disc ratio progression among individuals with glaucoma or glaucoma suspect following short-term ICS use.

Intensive breeding and selection on desired traits have produced high rates of inherited diseases in dogs. Hereditary retinal degeneration, often called progressive retinal atrophy (PRA), is prevalent in dogs with disease entities comparable to human retinitis pigmentosa (RP) and Leber's congenital amaurosis (LCA). Recent molecular studies in the English Springer Spaniel (ESS) dog have shown that PRA cases are often homozygous for a mutation in the RPGRIP1 gene, the defect also causing human RP, LCA, and cone rod dystrophies. The present study characterizes the disease in a group of affected ESS in USA, using clinical, functional, and morphological studies. An objective evaluation of retinal function using electroretinography (ERG) is further performed in a masked fashion in a group of American ESS dogs, with the examiner masked to the genetic status of the dogs. Only 4 of 6 homozygous animals showed clinical signs of disease, emphasizing the need and importance for more precise studies on the clinical expression of molecular defects before utilizing animal models for translational research, such as when using stem cells for therapeutic intervention.

Objectives: A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement., Design/setting/participants: Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders., Intervention: The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs., Results: The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups., Conclusion and Implications: Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Pain management for older adults residing in nursing homes continues to present multifaceted challenges to health care practitioners and researchers. This study, which focuses on improvement in pain assessment and management, is a secondary analysis of data from a larger study, which used an intervention simultaneously directed at all levels of staff with change in quality measure (QM)/quality indicator (QI) scores to determine improvement in resident outcomes. We anticipated that focused improvement efforts in resident care regarding pain management would be reflected by correspondingly lower QM/QI scores over time. Findings of increased QM/QI scores may be positive in that they may point to increased attention by staff regarding pain management for residents., (Copyright 2010, SLACK Incorporated.)

Objective: There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes., Methods: Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures., Results: Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups., Discussion: Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover., Conclusions: Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology., (Copyright 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Background: The 1.6 million nursing home residents in the United States are at high risk for adverse effects from medication errors. In an attempt to decrease medication errors and improve safety practices, from 2003 through 2007 the study investigators partnered with five Midwestern nursing homes in implementing electronic point-of-care medication administration records (eMARs) and focused quality improvement (QI) efforts., Methods: The eMAR, designed by a vendor as a part of a larger integrated electronic health record, provided a point of information integration for a variety of users, including practitioners, nursing staff, medication administrators, and nursing home leadership. At each nursing home, a medication safety team guided the transition from traditional paper-based systems to the eMAR., Results: The implementation and integration of the eMAR was monitored in more than 300 hours of detailed observation, resulting in nearly 16,000 medication doses across approximately 200 medication administrations (passes) for 3,700 residents. The types of medication errors most receptive to the combined impact of the eMAR and focused QI efforts were late and omitted (or missing) medications., Discussion: Technology provided the structures and processes that improved communication and integrated complex processes. Yet, regardless of how effectively the technology was designed, it was "laid upon" nursing home medication administration systems that were archaic and fragmented. The implementation of technology could not solve chronic structure and process issues in isolation. However, using the technology to streamline processes, support effective decision making, integrate complex tasks, and bring real-time data to a medication safety team provided an effective mechanism to maximize the impact of technology and to minimize the unintended consequences of large-scale change.

Background: C-peptide is a marker of insulin secretion in diabetic patients. We assessed within- and between-laboratory imprecision of C-peptide assays and determined whether serum calibrators with values assigned by mass spectrometry could be used to harmonize C-peptide results., Methods: We sent 40 different serum samples to 15 laboratories, which used 9 different routine C-peptide assay methods. We also sent matched plasma samples to another laboratory for C-peptide analysis with a reference mass spectrometry method. Each laboratory analyzed 8 of these samples in duplicate on each of 4 days to evaluate within- and between-day imprecision. The same 8 samples were also used to normalize the results for the remaining samples to the mass spectrometry reference method., Results: Within- and between-run CVs ranged from <2% to >10% and from <2% to >18%, respectively. Normalizing the results with serum samples significantly improved the comparability among laboratories and methods. After normalization, the differences among laboratories in mean response were no longer statistically significant (P = 0.24), with least-squares means of 0.93-1.02., Conclusions: C-peptide results generated by different methods and laboratories do not always agree, especially at higher C-peptide concentrations. Within-laboratory imprecision also varied, with some methods giving much more consistent results than others. These data show that calibrating C-peptide measurement to a reference method can increase comparability between laboratories.

Field test results are reported for the Observable Indicators of Nursing Home Care Quality Instrument-Assisted Living Version, an instrument designed to measure the quality of care in assisted living facilities after a brief 30-minute walk-through. The OIQ-AL was tested in 207 assisted-living facilities in two states using classical test theory, generalizability theory, and exploratory factor analysis. The 34-item scale has a coherent six-factor structure that conceptually describes the multidimensional concept of care quality in assisted living. The six factors can be logically clustered into process (Homelike and Caring, 21 items) and structure (Access and Choice; Lighting; Plants and Pets; Outdoor Spaces) subscales and for a total quality score. Classical test theory results indicate most subscales and the total quality score from the OIQ-AL have acceptable interrater, test-retest, and strong internal consistency reliabilities. Generalizability theory analyses reveal that dependability of scores from the instrument are strong, particularly by including a second observer who conducts a site visit and independently completes an instrument, or by a single observer conducting two site visits and completing instruments during each visit. Scoring guidelines based on the total sample of observations (N = 358) help guide those who want to use the measure to interpret both subscale and total scores. Content validity was supported by two expert panels of people experienced in the assisted-living field, and a content validity index calculated for the first version of the scale is high (3.43 on a four-point scale). The OIQ-AL gives reliable and valid scores for researchers, and may be useful for consumers, providers, and others interested in measuring quality of care in assisted-living facilities.

Background: The purpose of this study was to assess the possible role of major stressful life events, complicated grief, and depression in the pathogenesis of benign essential blepharospasm (BEB) and hemifacial spasm (HFS)., Methods: This was a case-control study involving 23 participants with BEB/HFS and 23 control subjects, comparing the frequency of major stressful life events, depression on the Beck Depression Inventory-II, and complicated grief on the Inventory of Complicated Grief., Results: There was no difference in the rate of depression or complicated grief between participants with BEB/HFS (57%) and control subjects (48%). Participants with BEB/HFS experienced a significantly (P = 0.0048) shorter time interval between two major stressful life events (median, 0.3 year) than did the control group (median, 3.0 years). The proportion of participants who had suffered two major stressful lifetime events separated by 1 year or less was significantly greater for participants with BEB/HFS than for control subjects (P = 0.0007)., Conclusions: The onset of BEB and HFS was often preceded by a major lifetime stressor. The development of these conditions was significantly related to the number of stressful life events occurring within the preceding year rather than to the total number of stressful life events. Subjects who sustain closely spaced stressful life events may be at increased risk of developing BEB and HFS.

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naïve observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Background and Objective: Generalizability of clinical predictors for mortality from lower respiratory infection (LRI) in nursing home residents has not been assessed for residents with dementia., Study Design and Setting: In prospective cohort studies of LRI in 61 nursing homes in the Netherlands (n = 541) and 36 nursing homes in Missouri, USA (n = 564), we examined 14-day and 1- and 3-month mortality in residents with dementia who were treated with antibiotics., Results: A logistic model predicting 14-day mortality derived from Dutch data included eating dependency, elevated pulse, decreased alertness, respiratory difficulty, insufficient fluid intake, high respiratory rate, male gender, and pressure sores. After adjusting coefficients with the heuristic shrinkage factor, the 14-day model showed good discrimination and calibration in both datasets. The apparent c-statistic for the original Dutch model was 0.80 (after correction for optimism, it was 0.75); the c-statistic was 0.74 in the U.S. validation population. The models predicting 1- and 3-month mortality showed moderate performance. A scoring system for estimating 14-day mortality performed equally well as the original model., Conclusion: We identified a set of credible clinical predictors that are easily assessed and demonstrated validity in identifying residents at low risk of dying from LRI across different nursing home populations. This tool should inform decision-making for families and doctors.

The primary aim of this NINR-NIH-funded field test in 407 nursing homes in 3 states was to complete the development of and conduct psychometric testing for the Observable Indicators of Nursing Home Care Quality Instrument (Observable Indicators, OIQ). The development of the OIQ was based on extensive qualitative and iterative quantitative work that described nursing home care quality and did initial validity and reliability field testing of the instrument in 123 nursing homes in 1 state. The scale is meant for researchers, consumers, and regulators interested in directly observing and quickly evaluating (within 30 minutes of observation) the multiple dimensions of care quality in nursing homes. After extensive testing in this study, the Observable Indicators instrument has been reduced to 30 reliable and discriminating items that have a conceptually coherent hierarchical factor structure that describes nursing home care quality. Seven first-order factors group together into two second-order factors of Structure (includes Environment: Basics and Odors) and Process (includes Care Delivery, Grooming, Interpersonal Communication, Environment: Access, and Environment: Homelike) that are classic constructs of Quality, which was the third-order factor. Internal consistency reliability for the 7 first-order factors ranged from .77 to .93. Construct validity analyses revealed an association between survey citations and every subscale as well as the total score of the OIQ instrument. Known groups analysis revealed expected trends in the OIQ scores. The Observable Indicators instrument as a whole shows acceptable interrater and test-retest reliabilities, and strong internal consistency. Scale subscales show acceptable reliability as well. Generalizability Theory analyses revealed that dependability of scores can be improved by including a second site observer, or by revisiting a site. There is a small additional benefit from increasing observers or visits beyond two.

Patients with advanced heart and lung disease experience exacerbations resulting in hospitalizations and interventions the patient may not desire. Strategies are needed that address end of life issues, honor preferences, and improve care without increasing cost. This study examines the impact on hospitalization and care cost of an integrated system of end of life care and interdisciplinary home care for mid-Missouri veterans with advanced congestive heart failure or chronic obstructive pulmonary disease.

Purpose: Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different., Methods: We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity., Results: Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality., Conclusion: Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment.

Pregnancy is considered a teachable moment for helping women who smoke to quit, yet few studies have examined smoking behavior of expectant fathers. The present study considers the possibility that pregnancy is a teachable moment for expectant fathers as well and describes smoking and associated behaviors of men during their partner's pregnancy. Participants were 138 low-income men living with their pregnant partners. Using telephone interviews, we found 63% of the men had smoked at least 100 cigarettes in their lifetime. Current smoking was reported by 49.3% of expectant fathers (39.1% daily smoking; 10.2% some days). Expectant fathers' current smoking was associated with having a lower level of education (p<.0001), pregnant partner being a current smoker (p=.0002), higher quantity of alcohol consumption per day of drinking (p=.0003), and absence of smoking prohibitions inside the home (p<.0001). In the past year, 70.1% of the current smokers tried to quit. We found high rates of smoking in low-income expectant fathers, and an expectant father's smoking during his partner's pregnancy was associated with his pregnant partner continuing to smoke. A majority of expectant fathers identified as current smokers tried to quit in the past year or indicated an intention to quit in the near future. Intervention during pregnancy that targets pregnant women and expectant fathers who smoke could lead to more households without tobacco use and thus have positive implications for paternal, maternal, and family health. Further clinical and research attention is needed to address the smoking behaviors of both expectant fathers and their pregnant partners.

Objectives: To measure pressure ulcer quality indicator (QI) scores and to describe the self-reported skin integrity assessment, pressure ulcer risk assessment, and pressure ulcer prevention and treatment practices in long-term care facilities (LTCFs)., Design: Retrospective analysis of a large data set and comparative survey., Setting: LTCFs in Missouri., Participants: Three hundred sixty-two LTCFs participated in the survey. Three hundred twenty-one facilities had pressure ulcer QI scores between April 1 and September 30, 1999., Measurements: Pressure ulcer QI scores, Pressure Ulcer Prevention & Treatment Practices Survey., Results: The mean+/-standard deviation pressure ulcer QI score was 10.9+/-6.2%, with a risk-adjusted score of 15.7+/-8.9% for high-risk residents and 3.1+/-3.6% for low-risk residents. Minimizing head-of-bed elevation to less than 30 degrees was used by fewer than 20% of facilities. More than 40% of facilities used a risk assessment tool that was not evidence based. Fewer than 13% of facilities used the Agency for Health Care Policy and Research pressure ulcer prevention and treatment guidelines. No relationship was found between the number of prevention strategies (P=.892) or the number of treatment strategies (P=.921) and the pressure ulcer QI scores., Conclusion: Valid and reliable pressure ulcer risk assessment tools are seriously underused. Evidence-based pressure ulcer prevention and treatment guidelines appear to be rarely implemented. This study provides a basis for developing educational and quality improvement programs and future research related to pressure ulcer prevention and treatment in LTCFs.

Aged individuals suffer from multiple dysfunctions during skeletal muscle atrophy. The purpose of this study was to determine differential changes in gene expression in atrophied soleus muscle induced by hindlimb immobilization in young (3-4 months) and old (30-31 months) rats. The hypothesis was that differentially expressed mRNAs with age-atrophy interactions would reveal candidates that induce loss of function responses in aged animals. Each muscle was applied to an independent set of Affymetrix micoarrays, with 385 differentially expressed mRNAs with atrophy and 354 age-atrophy interactions detected by two-factor ANOVA (alpha of 0.05 with a Bonferroni adjustment). Functional trends were observed for 23 and 15 probe sets involved in electron transport and the extracellular matrix, respectively, decreasing more in the young than in the old. Other functional categories with atrophy in both ages included chaperones, glutathione-S-transferases, the tricarboxylic acid cycle, reductions in Z-line-associated proteins and increases in probe sets for protein degradation. Surprisingly, myosin heavy chain IIb and IIx mRNAs were suppressed in the atrophied soleus muscle of old rats as opposed to the large increases in the young animals (16- and 25-fold, respectively, with microarrays, and 61- and 68-fold, respectively, with real-time PCR). No significant changes were observed in myosin heavy chain IIb and IIx mRNA with micoarrays in the atrophied soleus muscles of old rats, but they were found to increase six- and fivefold, respectively, with real-time PCR. Therefore, deficiencies in pre-translational signals that normally upregulate myosin heavy chain IIb and IIx mRNAs during atrophy may exist in the soleus muscle of old animals.

After cessation of hindlimb immobilization, which resulted in a 27-37% loss in soleus mass, the atrophied soleus muscle of young but not old rats regrows to its mass before treatment. We hypothesized that during remobilization the mRNA levels of growth potentiating factor(s) would be present in the soleus muscle of young (3- to 4-mo-old) but absent in old (30- to 31-mo-old) Fischer 344 x Brown Norway rats or that mRNAs for growth inhibitory factor(s) would be absent in young but present in old. Gene expression levels of >24,000 transcripts were determined by using Affymetrix RGU34A-C high-density oligonucleotide microarrays in soleus muscles at 3, 6, 10, and 30 days of remobilization after cessation of a 10-day period of hindlimb immobilization. Each muscle sample was applied to an independent set of arrays. Recovery-related differences were determined by using a three-factor ANOVA with a false discovery rate-adjustment of P = 0.01, which yielded 64 significantly different probe sets. Elfin, amphiregulin, and clusterin mRNAs were selected for further confirmation by real-time PCR. Elfin mRNA levels were less in old than in young rats at 6, 10, and 30 days of remobilization. Amphiregulin expression exhibited a unique spike on the 10th day of successful regrowth in young rats but remained unchanged old. Clusterin mRNA was unchanged in young muscles but was elevated on the 3rd, 6th, and 10th days of recovery in old soleus muscles. The mRNAs identified as differentially expressed between young and old recovery may modulate muscle growth that could highlight new candidate mechanisms to explain the failure of old soleus muscle to recover lost muscle mass.

The direction of change in skeletal muscle mass differs between young and old individuals, growing in young animals and atrophying in old animals. The purpose of the experiment was to develop a statistically conservative list of genes whose expression differed significantly between young growing and old atrophying (sarcopenic) skeletal muscles, which may be contributing to physical frailty. Gene expression levels of >24,000 transcripts were determined in soleus muscle samples from young (3-4 mo) and old (30-31 mo) rats. Age-related differences were determined using a Student's t-test (alpha of 0.05) with a Bonferroni adjustment, which yielded 682 probe sets that differed significantly between young (n = 25) and old (n = 20) animals. Of 347 total decreases in aged/sarcopenic muscle relative to young muscles, 199 were functionally identified; the major theme being that 24% had a biological role in the extracellular matrix and cell adhesion. Three themes were observed from 213 of the 335 total increases in sarcopenic muscles whose functions were documented in databases: 1) 14% are involved in immune response; 2) 9% play a role in proteolysis, ubiquitin-dependent degradation, and proteasome components; and 3) 7% act in stress/antioxidant responses. A total of 270 differentially expressed genes and ESTs had unknown/unclear functions. By decreasing the sample sizes of young and old animals from 25 x 20 to 15 x 15, 10 x 10, and 5 x 5 observations, we observed 682, 331, 73, and 3 statistically different mRNAs, respectively. Use of large sample size and a Bonferroni multiple testing adjustment in combination yielded increased statistical power, while protecting against false positives. Finally, multiple mRNAs that differ between young growing and old, sarcopenic muscles were identified and may highlight new candidate mechanisms that regulate skeletal muscle mass during sarcopenia.

Fluoroquinolone (FQ) antimicrobial agents are used extensively in human and veterinary medicine. Widespread use of any antimicrobial agent can apply selective pressure on populations of bacteria, which may result in an increase in the prevalence of antimicrobial-resistant isolates. Antimicrobial-susceptibility data on bacteria isolated from the canine urinary tract by the University of Missouri-Columbia Veterinary Medical Diagnostic Laboratory, Columbia, MO, were used to determine whether there has been an increase in the prevalence of FQ-resistant bacteria over time. Between January 1992 and December 2001, minimum inhibitory concentrations of either ciprofloxacin (1992-1998) or enrofloxacin (1998-2001) were determined for 1,478 bacterial isolates from the canine urinary tract. The predominant bacterial species isolated were Escherichia coli (547 isolates), Proteus mirabilis (156), and Staphylococcus intermedius (147). In all, there were 13 bacterial species with more than 25 isolates each. A significant increase in the overall proportion of resistant bacterial isolates was documented from 1992 to 2001 (Cochran-Armitage test for trend, P < 0.0001). The same increase in resistant isolates was documented when either ciprofloxacin or enrofloxacin was analyzed separately (P < 0.0001 and P < 0.0002, respectively). No difference was detected in rates of bacterial FQ resistance with regard to the sex of the dog from which the bacteria were isolated. The frequency with which some bacterial species were isolated differed with the sex of the infected dog. Proteus mirabilis was found more often in females (P < 0.0001), whereas beta hemolytic Streptococcus spp., were found more often in males (P = 0.0003). Although the overall efficacy of FQ antimicrobials remained high with greater than 80% of isolates being susceptible, the data demonstrated an increase in the proportion of resistant bacteria isolated from the urinary tract of the dog.

This cross-sectional study assessed the relationship between the degree of optic nerve pallor (optic atrophy) and visual function. Using a set of "gold standard" stereoscopic slides, the severity of optic atrophy for 270 eyes, each having sustained a bout of optic neuropathy, was graded. Good visual acuity was found in 55/86 (64.0%) mild, 54/119 (45.4%) moderate, and 21/65 (32.3%) marked optic atrophy eyes. Good visual field was found in 6/28 (21.4%) mild, 4/43 (9.3%) moderate, and 2/28 (7.1%) marked optic atrophy eyes. Good color vision was found in 31/46 (67.4%) mild, 12/62 (19.4%) moderate, and 7/31 (22.6%) marked optic atrophy eyes. A significant rank correlation was observed between optic atrophy and visual acuity (P < 0.001; rs = 0.356), visual field (P < 0.001; rs = -0.398), and color vision (P < 0.001; rs = -0.492). As the graded severity of optic atrophy increases, the proportion of eyes with good visual function decreases. Visual field, rather than visual acuity or color vision, appears to be a better indicator of the severity of visual loss, when optic atrophy is present.

Objective: To determine whether health outcomes of children who have asthma can be improved through the use of an Internet-enabled interactive multimedia asthma education program., Methods: Two hundred twenty-eight children with asthma visiting a pediatric pulmonary clinic were randomly assigned to control and intervention groups. Children and caregivers in both groups received traditional patient education based on the National Asthma Education and Prevention Program. Intervention group participants received additional self-management education through the Interactive Multimedia Program for Asthma Control and Tracking. Pediatric Asthma Care Knowledge Survey, Pediatric Asthma Caregiver's Quality of Life Questionnaire, asthma symptom history, spirometry, and health services utilization data were collected at the initial visit and at 3 and 12 months., Results: Interactive Multimedia Program for Asthma Control and Tracking significantly increased asthma knowledge of children and caregivers, decreased asthma symptom days (81 vs 51 per year), and decreased number of emergency department visits (1.93 vs 0.62 per year) among the intervention group participants. The intervention group children were also using a significantly lower average daily dose of inhaled corticosteroids (434 vs 754 micro g [beclomethasone equivalents]) at visit 3. Asthma knowledge of all 7- to 17-year-old children correlated with fewer urgent physician visits (r = 0.37) and less frequent use of quick-relief medicines (r = 0.30)., Conclusions: Supplementing conventional asthma care with interactive multimedia education can significantly improve asthma knowledge and reduce the burden of childhood asthma.

Background: Stress has been proposed as one of the contributing factors of central serous chorioretinopathy (CSC). Because the number of women in the workforce has increased dramatically in past decades, their presumed additional stress may increase their risk for CSC. We performed a study to determine whether the ratio of men to women in whom CSC was diagnosed remained constant between 1970 and 2000 in our patient population., Methods: We reviewed the medical records of 88 patients (69 males and 19 females) in whom CSC was diagnosed between 1970 and 2000. Only patients who were noted to have subretinal fluid on stereoscopic colour fundus photographs and focal retinal pigment epithelial hyperfluorescence on fluorescein angiography were included. Logistic regression analysis was performed to determine the probability of a patient's being male over the study period., Results: No significant change was found in the proportion of male patients in whom CSC was diagnosed over the study period (p = 0.69)., Interpretation: The ratio of males to females with a diagnosis of CSC did not change significantly over 30 years in our study population. If stress is a contributing factor of CSC and if women are experiencing increased stress from changing societal roles, women may have different adaptations to stress than men, or other mechanisms of CSC formation may be present.

Despite over 3,000 articles published on dystrophin in the last 15 years, the reasons underlying the progression of the human disease, differential muscle involvement, and disparate phenotypes in different species are not understood. The present experiment employed a screen of 12,488 mRNAs in 16-wk-old mouse mdx muscle at a time when the skeletal muscle is avoiding severe dystrophic pathophysiology, despite the absence of a functional dystrophin protein. A number of transcripts whose levels differed between the mdx and human Duchenne muscular dystrophy were noted. A fourfold decrease in myostatin mRNA in the mdx muscle was noted. Differential upregulation of actin-related protein 2/3 (subunit 4), beta-thymosin, calponin, mast cell chymase, and guanidinoacetate methyltransferase mRNA in the more benign mdx was also observed. Transcripts for oxidative and glycolytic enzymes in mdx muscle were not downregulated. These discrepancies could provide candidates for salvage pathways that maintain skeletal muscle integrity in the absence of a functional dystrophin protein in mdx skeletal muscle.

Background: Colonoscopy can be difficult in some women who have undergone hysterectomy, which can be associated with a fixed, angulated sigmoid colon caused by postoperative pelvic adhesions. Our goal was to determine whether colonoscopy is easier and more comfortable for women after hysterectomy when performed with a pediatric colonoscope, which is thinner in diameter and more flexible than a standard "adult" colonoscope., Methods: One hundred women with a history of hysterectomy undergoing outpatient colonoscopy were randomized in unblinded fashion to colonoscopy with a standard colonoscope (CF-100L or CF-Q140L, Olympus) or with a pediatric colonoscope (PCF-100, Olympus). All procedures were performed by a faculty endoscopist and timed. After examination, the endoscopist graded procedure difficulty, and patients were given a questionnaire that assessed their experience., Results: The cecum was intubated more frequently in the pediatric colonoscope group than in the standard colonoscope group (96.1% vs. 71.4%, p < 0.001). Success increased in the standard colonoscope group to 89.8% when the pediatric colonoscope was used to complete the examination. There were no differences in the two groups in terms of mean total procedure times (21.4 minutes vs. 22.6 minutes), mean doses of meperidine administered (57 mg both groups), mean doses of midazolam administered (1.5 mg vs. 1.7 mg), scales of procedure difficulty as graded by the endoscopists, and comfort scales as graded by patients. For the cases in which the cecum was intubated, the mean time to reach the cecum (11.7 minutes for the pediatric colonoscope group vs. 12.7 minutes for the adult) was similar., Conclusions: The pediatric colonoscope is a reasonable choice for colonoscopy in women who have had a hysterectomy. Alternatively, if the endoscopist elects to start the procedure with a standard colonoscope, it is helpful to have a pediatric colonoscope available for use should a fixed, angulated sigmoid colon be encountered that cannot be easily or safely traversed with the standard colonoscope.

Purpose: By use of flow cytometry (FCM), lymphocyte subsets were evaluated with fluorochrome-labeled monoclonal antibodies (MoAbs). Recent fluorescein angiography (FA) produces temporary elevation of serum background fluorescence at certain wavelengths of light, producing falsely decreased lymphocyte subset quantitations. The authors evaluated the duration of this effect on one subset of lymphocytes after FA., Methods: CD4 counts were determined by FCM before and 10 minutes, 1, 6, and 24 hours after injection of fluorescein dye in 12 patients. The MoAbs used were directly conjugated to fluorescein isothiocyanate (FITC) or phycoerythrin (PE)., Results: Using FITC-labeled MoAbs, falsely decreased CD4 counts occurred in all patients at 10 minutes and in all but one patient 1 hour after injection. Return to baseline levels occurred in 50% (95% confidence interval [CI], 0.21, 0.79) by 6 hours and in 75% (95% CI, 0.43, 0.95] by 24 hours. No such effect was observed using PE-labeled MoAbs., Conclusions: Falsely decreased CD4 values as determined by FCM were present immediately after FA in all 12 patients and persisted 24 hours in some patients when FITC-labeled MoAbs were used. CD4 evaluation should be delayed in patients who have undergone recent FA or the analysis should be performed with PE-labeled MoAbs.

Previously developed histological age-estimating methods have been based on samples lacking interpopulation variability. A comparison of age-associated rib histomorphometrics between an European-American sample and an African-American sample indicates that ethnicity can have a significant effect on osteon population density (OPD), osteon cross-sectional area (On.Ar), and relative cortical area (Ct.Ar/Tt.Ar). Based upon these findings, new histological age-predicting formulae are presented that are recommended when estimating age for African-American or European-American skeletal remains. A general formula that is applicable to remains of unknown ethnicity is also provided.

Patients with high transthoracic impedance are reported to be at higher risk of poor outcomes when treated by present defibrillators. This study evaluates the defibrillation efficacy of biphasic truncated exponential (BTE), quadriphasic truncated exponential (QTE), and Edmark waveforms at simulated low, average, and high impedance levels. Waveforms were tested at 2 energy levels in random order in anesthetized dogs (n = 15, 16.9 +/- 1.2 kg), and a supplemental study estimated the ED50 peak current for BTE and QTE at a simulated high impedance level. Overall, BTE and QTE were equivalent, and both were superior to Edmark at equal delivered energies (P<.0001). However, in simulated high impedance patients at 24 J, QTE was superior to BTE (71% vs. 49%, P =.011 (borderline significance-see text)). Supplemental study, QTE mean ED50 peak current was lower than BTE (7.9 vs. 8.9 A, P =.0049). QTE and BTE waveforms were superior to Edmark at all studied conditions, but QTE appears to be superior to BTE in simulated high impedance patients.