Search

Photocatalytic reduction of hexavalent Cr(VI) couping oxidative degradation of organic contamination is an emerging and practical approach for water treatment. In this study, Z-scheme g-C3N4/Bi2S3 heterojunctions with intimate interface were successfully synthesized by direct growth of Bi2S3 on g-C3N4 surface. Notably, the photocatalytic performance of Z-scheme g-C3N4/Bi2S3 was influenced by g-C3N4 content. The optimized 2% g-C3N4/Bi2S3 heterojunction shows the highest photocatalytic reduction performance with 93.4% reduction efficiency of Cr(VI) under UV-visible light due to efficient separation and transfer of charge carriers and proper band structure. Furthermore, 2% g-C3N4/Bi2S3 can degrade tetracycline and Rhodamine B. Free radical capturing and quantitative tests indicate that holes and superoxide radicals are primary active species for the degradation of organic pollutants, while Cr(VI) was reduced to Cr(III) by the photogenerated electrons. Overall, this study provides new insight into the synthesis of high-performance Z-scheme heterojunctions for the future advancement of photocatalysis technology.

In an increasingly complex exploration environment, the acquired seismic data are incomplete and irregular, and field interference often seriously affects the S/N (signal-to-noise ratio) of complex seismic signals. At the same time, weak seismic signals in deep geophysical target are always covered by field noise. How to effectively reconstruct irregular seismic signals and suppress field noise is still a key problem in high-precision seismic exploration. The paper systematically analyzes the inverse problem of sparse optimization for noise suppression of field interferences in irregular seismic data under the framework of 3D curvelet transform, and proposes an amplitude-preserving reconstruction technique for 3D irregular data based on improved POCS algorithm with iterative soft threshold. On the basis of achieving highly sparse representation, the effective seismic signal is inversed iteratively through the change of S/N of adjacent traces to effectively improve the S/N of complex seismic data. At the same time, when solving the sparse optimization problem, the dividing point of noise and effective wave curvelet coefficient is obtained by constructing the ratio formula of curvelet coefficient, which lays the foundation for accurately suppressing noises and reconstructing weak seismic signals. The application of actual data shows that the method can suppress the noises in the complex seismic data, recover the missing data effectively, and improve the fidelity of the reconstructed data.

Electronic health records enable automated data capture for risk models but may introduce bias. We present the Philips Critical Care Outcome Prediction Model (CCOPM) focused on addressing model features sensitive to data drift to improve benchmarking ICUs on mortality performance.Retrospective, multicenter study of ICU patients randomized in 3:2 fashion into development and validation cohorts. Generalized additive models (GAM) with features designed to mitigate biases introduced from documentation of admission diagnosis, Glasgow Coma Scale (GCS), and extreme vital signs were developed using clinical features representing the first 24 hours of ICU admission.eICU Research Institute database derived from ICUs participating in the Philips eICU telecritical care program.A total of 572,985 adult ICU stays discharged from the hospital between January 1, 2017, and December 31, 2018, were included, yielding 509,586 stays in the final cohort; 305,590 and 203,996 in development and validation cohorts, respectively.None.Model discrimination was compared against Acute Physiology and Chronic Health Evaluation (APACHE) IVa/IVb models on the validation cohort using the area under the receiver operating characteristic (AUROC) curve. Calibration assessed by actual/predicted ratios, calibration-in-the-large statistics, and visual analysis. Performance metrics were further stratified by subgroups of admission diagnosis and ICU characteristics. Historic data from two health systems with abrupt changes in Glasgow Coma Scale (GCS) documentation were assessed in the year prior to and after data shift. CCOPM outperformed APACHE IVa/IVb for ICU mortality (AUROC, 0.925 vs 0.88) and hospital mortality (AUROC, 0.90 vs 0.86). Better calibration performance was also attained among subgroups of different admission diagnoses, ICU types, and over unique ICU-years. The CCOPM provided more stable predictions compared with APACHE IVa within an external cohort of greater than 120,000 patients from two health systems with known changes in GCS documentation.These mortality risk models demonstrated excellent performance compared with APACHE while appearing to mitigate bias introduced through major shifts in GCS documentation at two large health systems. This provides evidence to support using automated capture rather than trained personnel for capture of GCS data used in benchmarking ICUs on mortality performance.

Background Dental cusp angulation provides valuable insights into chewing efficiency and prosthesis safety. Artificial intelligence-enabled computing of cusp angles has potential important value, but there is currently no reliable digital measurement method as a cornerstone. Objectives To establish a digital method for measuring cusp angles and investigate inter-rater and intra-rater reliabilities. Methods Two cusp angles (angles α and β) of the first molar were measured on 21 plaster casts using a goniometer and on their corresponding digital models using PicPick software after scanning with a CEREC Bluecam three-dimensional (3D) intraoral scanner. Means ± standard deviations, as well as intraclass correlation coefficients (ICCs) and Pearson's correlation coefficients (PCCs) were calculated, and repeated measures analysis of variance was performed. The Bland–Altman method was used to calculate the difference and mean degree values of two measurement methods from both examiners, and the Bland–Altman diagram was drawn using MedCalc software. Results When the examiner was experienced, angle α was 139.19° ± 13.86°, angle β was 19.25° ± 6.86°, and a very strong positive correlation between the two methods was found (r > 0.9; p 0.05). The Bland–Altman diagram showed that the two methods were highly consistent. For inter-rater assessments, the ICC and PCC values of the cusp angulation using the digital method were all higher than the corresponding values measured on traditional casts. For intra-rater assessments, the ICC values of cusp angulation using the digital method were higher than the corresponding values measured on traditional plaster casts for both examiners. However, repeated measurements of the angle β of the inter-examiners revealed significant differences (p Conclusions Cusp angulation using 3D digital models is a clinical option and appears to improve the reliability of cusp angulation compared with measuring plaster casts using a goniometer. This variability was still evident when measuring small cusp angles using the digital model for inexperienced examiners.

To evaluate the accuracy of intraoral scanners by comparing the marginal fit of 70 all-ceramic crowns fabricated from both conventional impressions and intraoral scans.A total of 70 posterior teeth requiring single-crown restorations randomly underwent either intraoral scanning or conventional impression-taking followed by laboratory scanning of the casts in a parallel-group RCT. Subsequently, 70 monolithic all-ceramic crowns were CAD/CAM fabricated; only the impression technique differed. Marginal fit, internal fit, adjustment time required for insertion and occlusal contacts, and visual analog scale (VAS) scores assessing dentists' satisfaction with all of the crowns were clinically evaluated by a blinded and calibrated examiner. Data were analyzed using independent-samples t test and likelihood ratio test or Fisher exact test. All tests were performed with α = .05.The mean marginal fit with intraoral scanning (57.94 ± 22.51 μm) was better than with diagnostic cast scanning (82.98 ± 21.72 μm). The difference was statistically significant (P = .000). The differences in internal fit, adjustment time for crown insertion and occlusal contacts, and VAS scores were also significant, and the secondary outcomes were in favor of intraoral scanning.Within the limitations of this clinical trial, CAD/CAM-fabricated single-tooth restorations in the posterior region produced by an intraoral scanning technique using TRIOS was found to be a more accurate and efficient alternative to restorations based on conventional impressions in combination with the laboratory scanning technique.

In order to improve the visual effect of aerial images in foggy weather, a Retinex defogging algorithm combining dark channel priors is proposed to solve the phenomenon of insufficient defogging and over-enhancement of aerial defogging in Reinex defogging. First, the foggy original image is decomposed into foggy incident light components and foggy reflected light components by Retinex theory. Then, the principle of foggy image degradation is analyzed by an atmospheric scattering model, and the dark channel prior defogging algorithm is used to obtain the incident light component and reflected light component after defogging. Finally, a fog-free image was restored through the Reitnex model. The effectiveness of this algorithm is verified through experiments. By comparing and analyzing this algorithm with other defogging algorithms, this algorithm has higher contrast and color fidelity.

ObjectiveDescribe the changes in patient population, bed occupancy, severity of illness and ventilator requirements across a large health system in the greater New York City area during the pandemic response in comparison with the 2019 baseline.DesignObservational, descriptive study of ICUs monitored by a tele-ICU system across Northwell Health. Inclusion criteria: All patients admitted to Northwell Health tele-ICUs during 2019 and between March 23, 2020 and April 6, 2020.ExposureA data extract was developed to collect data every hour for each ICU bed in the Northwell tele-critical care program as a quality reporting initiative to understand ICU capacity and resource utilization. A similar extract was developed for each hour of 2019.Main Outcomes and MeasuresAverage of any given hour during the pre-COVID-19 and pandemic periods for the following metrics: proportion of beds occupied, proportion of ventilated patients, severity of illness (measured by the ICU Discharge Readiness Score (DRS)), and length of stay (LOS).ResultsHourly analysis of data from 186 ICU beds from 14 ICUs and 9 hospitals were included, representing 10,714 patients in 2019 and 465 patients between March 23 and April 6, 2020. Average hourly occupancy increased from 64% to 78%, while the proportion of patients invasively ventilated increased from 33.9% to 84.2%. Median DRS (severity of illness score) increased from 1.08 (IQR: 0.24-6.98) to 39.38 (IQR: 12.00-71.28). Proportion of patients with Hispanic ethnicity doubled (7.8% to 16.6%; pConclusions and RelevanceIn addition to the expected increase in ICU occupancy and ventilator requirements, this large group of ICUs in midst of the COVID-19 epidemic are faced with managing a cohort of ICU patients with a dramatically higher severity of illness than their typical census.

A new type of metal organic frame-based magnetic composite adsorbent UiO-66-NH2/graphene oxide/Fe3O4 was used to eliminate the adverse effects of boron in the desalinated seawater. Through serial characterization, it was found that this adsorbent has the advantages of strong magnetic response, good pore structure and abundant functional groups. On the basis of single-factor experiments on various influencing factors, the simulation and prediction capabilities of the response surface method and artificial neural network method for the adsorption process were studied and compared. Both methods shown strong capacity to make effective prediction on the process of adsorption. However, the error of response surface method is smaller than the error of artificial neural network method. Result of optimization by response surface method shows that the optimal conditions of adsorbent dosage, pH, and temperature are 99.1 mg/L, 3.38 and 318K. Following the above conditions, the boron adsorption capacity of the adsorbent obtained in the real desalinated seawater environment is 22.46 mg/g. In addition, the adsorbent shows good recyclability. Pseudo-second-order kinetic model, intra-particle diffusion model, and Langmuir isotherm model are all suitable for describing adsorption process. Thermodynamic research results reveal the fact that this process is spontaneous and endothermic, and the adsorption of boron by the adsorbent is a composite process consisting of physical adsorption and chemical adsorption.

Evaluate the accuracy of different ICU risk models repurposed as continuous markers of severity of illness.Nonintervention cohort study.eICU Research Institute ICUs using tele-ICU software calculating continuous ICU Discharge Readiness Scores between January 2013 and March 2016.Five hundred sixty-one thousand four hundred seventy-eight adult ICU patients with an ICU length of stay between 4 hours and 30 days.Not available.Hourly Acute Physiology and Chronic Health Evaluation IV, Sequential Organ Failure Assessment, and Discharge Readiness Scores were calculated beginning hour 4 of the ICU stay. Primary outcome was the area under the receiver operating characteristic curve for the mean score with ICU mortality. Secondary outcomes included area under the receiver operating characteristic curves for ICU mortality with admission, median, maximum and last scores, and for death within 24 hours. The trajectories of each score were visualized by plotting the hourly averages against time in the ICU, stratified by mortality and length of stay. The area under the receiver operating characteristic curves for mean Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores were 0.90 (0.89-0.90), 0.86 (0.86-0.86), and 0.94 (0.94-0.94), respectively. The area under the receiver operating characteristic curves for hourly Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores predicting 24-hour mortality were 0.81 (0.81-0.81), 0.76 (0.76-0.76), and 0.86 (0.86-0.86). Discharge Readiness Scores had a higher area under the receiver operating characteristic curve than both Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment for each metric. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores increased throughout the first 24 hours in both survivors and nonsurvivors; Discharge Readiness Scores continuously decreased in survivors and temporarily decreased before increasing by hour 36 in nonsurvivors with longer length of stays.Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores all have relatively high discrimination for ICU mortality when used continuously; Discharge Readiness Scores tended to have slightly higher area under the receiver operating characteristic curves for each endpoint. These findings validate the use of these models on a population level for continuous risk adjustment in the ICU, although Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment appear slower to respond to improvements in patient status than Discharge Readiness Scores, and Discharge Readiness Scores may reflect physiologic improvement from interventions, potentially underestimating risk.

Z-scheme heterojunctions are considered as prospective photocatalysts for elimination of organic pollutants. However, the origin of enhanced oxidation ability of Z-scheme heterojunctions is not well understood, and the working mechanism based on internal electrical field is still ambiguous. Here, we report Z-scheme AgIn5S8/ZnO heterojunction with superior photocatalytic activity in degrading pharmaceutical pollutants and enhancing biodegradability of pharmaceutical wastewater. The average oxidation state (AOS) and carbon oxidation state (COS) of pharmaceutical wastewater are significantly increased from 0.42 to 1.35 and 2.94 after photocatalytic treatment of AgIn5S8/ZnO. The analysis on the origin of superior photocatalytic activity reveals that the internal electric field in AgIn5S8/ZnO heterojunction works as a driving force to facilitate efficient separation of photogenerated charge carriers via Z-scheme path, thus generating spatially separated holes and electrons with high redox ability and realizing effective elimination of pharmaceutical pollutants. This study provides deep insight into photocatalytic mechanism of Z-scheme heterojunction for efficacious elimination of organic pollutants and boosted biodegradability of pharmaceutical wastewater.

A high-precision wavelength demodulation method based on optical fiber Fabry-Perot tunable (FPT) filter is proposed for the fiber Bragg grating temperature sensing system. This algorithm uses the original sampling data obtained from the data acquisition card to simultaneously calculate the transmission spectrum of the F-P etalon (FPE) and the reflection spectrum of the fiber Bragg grating (FPG) sensors. In each scanning cycle, the transmission spectrum wavelength of the F-P etalon (FPE) is calibrated dynamically in real time, the reflectance spectrum central wavelength of the FPE sensors is calculated by referring to the transmission spectrum wavelength of the FPE that has been calibrated. It effectively weakens the perturbation effect caused by the nonlinear and non-reproducibility of narrowband light source from the fiber FPT filter, reduces the numerical error and effectively eliminates the pseudo peak of the FPE, and greatly improves the measurement accuracy of the system. Most programming languages can implement this algorithm. A temperature sensing experiment for the proposed method has been carried out. Results showed that the demodulation precision by our method could reach up to ±0.2 °C, wavelength demodulation accuracy 3 pm.

Background Longitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks. Methods Data representing 991,571 consecutive critical care visits to 160 US adult ICUs from 2009 to 2013 from the eICU Research Institute clinical practice database were used to quantitate patient characteristics, APACHE IV–based acuity predictions, treatments, and outcomes. Analyses for changes over time were performed for patient characteristics, entry and discharge locations, primary admission diagnosis, treatments, adherence to consensus ICU best practices, length of stay (LOS), and inpatient mortality. Results We detected significant trends for increasing age, BMI, and risk of mortality, higher frequency of admission from an ED and stepdown unit, and more frequent hospital discharge to substance abuse centers and skilled nursing facilities. Significantly more patients were admitted for sepsis, emphysema, coma, congestive heart failure, diabetic ketoacidosis, and fewer were admitted for asthma, unspecified chest pain, coronary artery bypass graft, and stroke care. The frequency of noninvasive mechanical ventilation and adherence to critical care best practices significantly increased, whereas the duration of renal replacement therapies, frequency of transfusions, antimicrobial use, critical care complications, LOS, and inpatient mortality decreased. Conclusions Analyses of patients, practices, and outcomes from a large geographically dispersed sample of adult ICUs revealed trends of increasing age and acuity, higher rates of adherence to best practice, use of noninvasive mechanical ventilation, and decreased use of antimicrobials, transfusions, and duration of renal replacement therapies. Acuity-adjusted LOS and in hospital mortality decreased.

OBJECTIVES To investigate the association between body mass index and mortality in a large, ICU population and determine if the relationship is observed among a subgroup of patients ordered early enteral nutrition. DESIGN Retrospective cohort study within a national clinical mixed ICU database of patients admitted between January 1, 2008, and June 30, 2015. SETTING Initial ICU admissions among patients monitored by tele-ICU programs and recorded in the Philips eICU Research Institute database. PATIENTS A total of 1,042,710 adult patient stays with ICU length of stay more than 24 hours, of which 74,771 were ordered enteral nutrition within the first 48 hours. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patient stays from 409 ICUs were included. The average age, Acute Physiology and Chronic Health Evaluation IV score, and hospital mortality were 63.6 years, 56.7, and 9.0%, respectively. Hospital mortality among body mass index categories was estimated by multivariable modified Poisson regression models. Compared with the body mass index category 25.0-29.9 kg/m, hospital mortality was higher among underweight (body mass index, < 18.5; relative risk, 1.35; 95% CI, 1.32-1.39), normal weight (body mass index, 18.5-24.9; relative risk, 1.10; 95% CI, 1.09-1.12), and the extremely obese (body mass index, ≥ 50.0; relative risk, 1.10; 95% CI, 1.05-1.15). However, the risk was not statistically different from patients with body mass index 30.0-49.9 kg/m. Among patients ordered early enteral nutrition, the risk of mortality in the body mass index category 25.0-29.9 kg/m was not statistically different from those in the normal weight or extremely obese groups. CONCLUSIONS A survival advantage for overweight and obese patients was observed in this large cohort of critically ill patients. However, among those ordered early enteral nutrition, the survival disadvantage for body mass index categories less than 25.0 kg/m was minimal or unobservable when compared with higher body mass index categories.

ObjectiveFew data exist regarding physician attitudes and implementation of family-centred rounds (FCR) in cardiovascular care. This study aimed to assess knowledge and attitudes among cardiologists and cardiology fellows regarding barriers and benefits of FCRs.MethodsAn electronic, web-based questionnaire was nationally distributed to cardiology fellows and attending cardiologists.ResultsIn total, 118 subjects were surveyed, comprising cardiologists (n=64, 54%) and cardiology fellows (n=54, 46%). Overall, 61% of providers reported participating in FCRs and 64% felt family participation on rounds benefits the patient. Both fellows and cardiologists agreed that family rounds eased family anxiety (fellows, 63%; cardiologists, 56%; p=0.53), improved communication between the medical team and the patient and family (fellows, 78%; cardiologists, 61%; p=0.18) and improved patient safety (fellows, 59%; cardiologists, 47%; p=0.43). Attitudes regarding enhancement of trainee education were similar (fellows, 69%; cardiologists, 55%; p=0.19). Fellows and cardiologists felt that family increased the duration of rounds (fellows, 78%; cardiologists, 80%; p=0.18) and led to less efficient rounds (fellows, 54%; cardiologists, 58%; p=0.27).ConclusionThe majority of cardiologists and fellows believed that FCRs benefited families, communication and patient safety, but led to reduced efficiency and longer duration of rounds.

OBJECTIVE To synthesize the existing literature on benefits and risks of anticoagulant use after traumatic brain injury (TBI). DESIGN Systematic review. A literature search was performed in MEDLINE, International Pharmaceutical Abstracts, Health Star, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on October 11, 2012, and updated on September 2, 2013, using terms related to TBI and anticoagulants. MAIN MEASURES Human studies evaluating the effects of post-TBI anticoagulation on venous thromboembolism, hemorrhage, mortality, or coagulation parameters with original analyses were eligible for the review. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was followed throughout the conduct of the review. RESULTS Thirty-nine eligible studies were identified from the literature, of which 23 studies with complete information on post-TBI anticoagulant use and patient outcomes were summarized in this review. Meta-analysis was unwarranted because of varying methodological design and quality of the studies. Twenty-one studies focused on the effects of pharmacological thromboprophylaxis (PTP) post-TBI on venous thromboembolism and/or progression of intracranial hemorrhage, whereas 2 randomized controlled trials analyzed coagulation parameters as the result of anticoagulation. CONCLUSION Pharmacological thromboprophylaxis appears to be safe among TBI patients with stabilized hemorrhagic patterns. More evidence is needed regarding effectiveness of PTP in preventing venous thromboembolism as well as preferred agent, dose, and timing for PTP.

Supplemental Material, JICM_R1Clean_supplementary_file for Red Blood Cell Product Transfusion Thresholds and Clinical Outcomes by Craig M. Lilly, Omar Badawi, Xinggang Liu, Gill Christine S., and Ilene Harris in Journal of Intensive Care Medicine

To avoid untoward changes when primary teeth are replaced by permanent teeth, resorption of the material used in primary teeth root canal filling should occur at the same rate as root resorption. The Aim of this study was to compare the success rates of a mixed primary root canal filling (MPRCF, ingredients: zinc oxide–eugenol [ZOE], iodoform, calcium hydroxide) to those of ZOE and Vitapex in pulpectomised primary molars. One hundred and sixty primary molars from 155 children (average age 5.88 ± 1.27 years) underwent two-visit pulpectomy using one of the three materials. The clinical and radiographic findings at 6, 12 and 18 months were assessed. At 6 and 12 months, the MPRCF and ZOE success rates were 100%. The Vitapex group showed clinical success rate and radiographic success rate of 100 and 94.5% at 6 months, and 80.4 and 60.7% at 12 months. The 18-month clinical success rates of the MPRCF, ZOE and Vitapex were 96.2, 92.2 and 71.4% and radiographic success rates were 92.5, 88.2 and 53.6%, respectively. There was a statistically significant difference in the success rates between MPRCF and Vitapex and no significant differences between MPRCF and ZOE. More MPRCF were resorbed at same rate with roots than ZOE and Vitapex. Early resorption of root filling resulted in more failure. The mixture of ZOE, iodoform and calcium hydroxide can be considered an effective root canal filling material in pulp involved primary teeth and had no adverse effect on tooth replacement. ChiCTR-TRC-14004938 . Registered 13 July 2014.

Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996-2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n=8), infection (n=10), and delirium (n=6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.

This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee-for-service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre-injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence-based management strategies in the post-acute setting.

Objectives: To assess the effectiveness of medications used in the management of Alzheimer's disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects. Design: Two-year (2007�2008) longitudinal study. Setting: Medicare enrollment and claims data linked to the Minimum Dataset 2.0. Participants: Older nursing home (NH) residents with newly diagnosed ADRD (n = 18,950). Measurements: Exposures included four medication classes: antidementia medications (ADMs), antipsychotics, antidepressants, and mood stabilizers. Outcomes included ADLs and cognition (Cognitive Performance Scale (CPS)). Marginal structural models were employed to account for time-dependent confounding. Results: The mean age was 83.6, and 76% of the sample was female. Baseline use of ADMs was 15%, antidepressants was 40%, antipsychotics was 13%, and mood stabilizers was 3%. Mean baseline ADL and CPS scores were 16.6 and 2.1, respectively. ADM use was not associated with change in ADLs over time but was associated with a slower CPS decline (slope difference: -0.09 points/year, 99% confidence interval (CI) = -0.14 to -0.03). Antidepressant use was associated with slower declines in ADL (slope difference: -0.36 points/year, 99% CI = -0.58 to -0.14) and CPS (slope difference: -0.12 points/year, 99% CI = -0.17 to -0.08). Sex modified the effect of both antipsychotic and mood stabilizer use on ADLs; female users declined most quickly. Antipsychotic use was associated with slower CPS decline (slope difference: -0.11 points/year, 99% CI = -0.17 to -0.06), whereas mood stabilizer use had no effect. Conclusion: Despite the observed statistically significantly slower declines in cognition with ADMs, antidepressants, and antipsychotics and the slower ADL decline found with antidepressants, it is unlikely that these benefits are of clinical significance.