An interactive feedback system for increasing hand antisepsis adherence in stationary intensive care.

BACKGROUND: Pathogens causing infections are in many cases transmitted via the hands of personnel. Thus, hand antisepsis has strong epidemiological evidence of infection prevention. Depending on various factors, hand antisepsis adherence ranges between 9.1% and 85.2%. AIM: To evaluate a new transponder system that reminded medical staff to use an alcohol-based hand rub based on indication by giving real-time feedback, to detect hand antisepsis adherence. METHODS: The monitoring system consisted of three components: a portable transponder detecting alcohol-based hand rub and able to give feedback; a beacon recognizing entries to and exits from the patient's surroundings; and a sensor placed at the hand-rub dispensers to count the number of hand rubs. With these components, the system provided feedback when hand antisepsis was not conducted although it was necessary according to moments 1, 4, and 5 of hand antisepsis. Adherence was measured in two use-cases with five phases, starting with the baseline measurement followed by intervention periods and phases without intervention to test the sustainability of the feedback. FINDINGS: Using the monitoring system, hand antisepsis adherence was increased by up to 104.5% in comparison to the baseline measurement. When the intervention ceased, however, hand antisepsis adherence decreased to less than or equal to the baseline measurement. CONCLUSION: A short-term intervention alone is not sufficient to lead to a long-term change in hand antisepsis adherence. Rather, permanent feedback and/or the integration in a multi-modal intervention strategy are necessary.

Safety and Efficacy of Induction Therapy With Thymoglobulin in AB0-Incompatible Kidney Transplantation.

INTRODUCTION: Data suggest an additional role of T cells in antibody-mediated rejections. In 2001 a protocol for AB0-incompatible kidney transplantation based on B-cell-depleting anti-CD20 antibody rituximab, antigen-specific blood group IgG immunoadsorption, intravenous immunoglobulins, and triple immunosuppression was introduced in Europe, which used induction therapy with the use of interleukin-2 receptor antibody (IL2-RA) basiliximab. We used thymoglobulin in AB0-incompatible patients as induction in the face of high immunologic risk. METHODS: We retrospectively evaluated a cohort of 9 AB0i living donation (LD) recipients from 2011 to 2014. Desensitization included blood group-specific immunoadsorption. Eighteen AB0-compatible LD recipients receiving induction therapy with thymoglobulin served as control subjects. Another control group consisted of 18 AB0-compatible LD recipients receiving basiliximab. Follow-up was 24 months. We captured graft function by estimating glomerular filtration rate (eGFR by Modification of Diet in Renal Disease formula), rejection episodes, and bacterial and viral infections. RESULTS: All patients experienced immediate graft function. No significant or clinical differences were observed regarding graft function, rejection rates, or infections between the groups, although there seemed to be slightly higher cytomegalovirus infection rates due to preemptive therapy strategy. CONCLUSIONS: Thymoglobulin appears to be similar in safety and efficacy to IL-2-antagonists in AB0i kidney transplantation.

First Treatment of Relapsing Rapidly Progressive IgA Nephropathy With Eculizumab After Living Kidney Donation: A Case Report.

BACKGROUND: IgA nephropathy (IGAN) rarely can present as a crescent and progressive form leading to end-stage renal disease (ESRD) in a short period of time. Recurrence of IGAN after kidney transplantation is frequent, and complement components such as C3, C4d, and C5 seem to be involved. We present a case of a young male patient with ESRD caused by rapidly progressive IGAN and who demonstrated rapid recurrence of crescentic IGAN after kidney donation. CASE REPORT: In September 2014, a 28-year-old male patient was hospitalized due to IGAN with 60% of crescents. Cyclophosphamide, steroids, and plasmapheresis did not prevent ESRD. After 8 months of peritoneal dialysis, the patient received a blood group-compatible living donor kidney from his 57-year-old mother. Immunosuppression consisted of tacrolimus, mycophenolic acid, and steroids without induction therapy. Acute graft failure occurred 2 months later, and graft biopsy results revealed recurrence of crescentic IGAN. Cyclophosphamide was added to tacrolimus and steroid treatment, but graft function could not be restored despite viable kidney tissue in repeated biopsy specimens. Rescue therapy with 4 single doses of eculizumab was introduced while hemodialysis had already been initiated. After a cumulative dose of 1800 mg of eculizumab, kidney function did not recover. CONCLUSIONS: In this case, eculizumab was not effective in treating IGAN recurrence after transplantation. Therapy was started late when hemodialysis had already been initiated; an earlier start of therapy might be more effective.

Successful Short-Term Intravenous Treatment of Disseminated Nocardia farcinica Infection with Severe Hyponatremia After Kidney Transplantation: A Case Report.

BACKGROUND: Nocardia is a genus of gram-positive Actinomycetes that are ubiquitous in decaying organic material, soil, and water. Some Nocardia species can infect humans, mainly by airborne transmission. Several reports describe disseminated infections, which are rare and mostly affect strongly immunocompromised patients because intact T-cell-mediated immunity is the major protective mechanism. CASE REPORT: We report a case of disseminated pulmonary, cerebral, and cutaneous infection with Nocardia farcinica in a 66-year-old kidney transplant recipient treated with low-dose triple immunosuppression. The patient was initially admitted because of severe hyponatremia and pneumonia with radiologic signs of pleural effusion. The infectious agent was isolated when cutaneous lesions developed. Oral trimethoprim/sulfamethoxazole treatment led to severe hyponatremia; therefore, long-term treatment with parenteral amikacin and minocycline was initiated. After 7 months of consistent intravenous treatment, the lesions completely resolved and treatment was stopped, against some expert suggestions. The patient had remained free of relapse at the time of writing. CONCLUSIONS: Disseminated Nocardia infection in immunocompromised patients is a rare but life-threatening disease. Owing to its infrequency, the variety of clinical patterns, antimicrobial resistance, and often fatal complications of standardized therapy, the diagnosis and treatment of this infection remain challenging and protracted.

[Combined use of irradiation and DNA tumor vaccine to treat canine oral malignant melanoma: a pilot study]. / Kombinierte Anwendung von Strahlentherapie und DNS Tumor Vakzine zur Behandlung des oralen malignen Melanoms beim Hund: Eine Pilotstudie.

Melanoma is the most common oral tumor in dogs, characterized by rapid growth, local invasion, and high metastatic rate. The goal of this study was to evaluate the combination of radiation therapy and DNA tumor vaccine. We hypothesized, that the concurrent use would not increase toxicity. Nine dogs with oral melanoma were treated with 4 fractions of 8 Gray at 7-day intervals. The vaccine was given 4 times every 14 days, beginning at the first radiation fraction. Local acute radiation toxicities were assessed according to the VRTOG toxicity scoring scheme over a time period of 7 weeks. In none of the evaluated dogs, mucositis, dermatitis and conjunctivitis exceeded grade 2. In 3 dogs mild fever, lethargy, and local swelling at the injection site were seen after vaccine application. In conclusion, the concurrent administration of radiation therapy and vaccine was well tolerated in all dogs.

Far-infrared optical conductivity of CeCu2Si2.

We investigated the optical reflectivity of the heavy-fermion metal CeCu(2)Si(2) in the energy range 3 meV-30 eV for temperatures between 4 and 300 K. The results for the charge dynamics indicate a behavior that is expected for the formation of a coherent heavy quasiparticle state: upon cooling the spectra of the optical conductivity indicate a narrowing of the coherent response. Below temperatures of 30 K a considerable suppression of conductivity evolves below a peak structure at 13 meV. We assign this gap-like feature to strong electron correlations due to the 4f-conduction electron hybridization.

Progesterone vs placebo therapy for women with epilepsy: A randomized clinical trial.

OBJECTIVE: To assess progesterone treatment of intractable seizures in women with partial epilepsy. METHODS: This randomized, double-blind, placebo-controlled, phase III, multicenter, clinical trial compared the efficacy and safety of adjunctive cyclic natural progesterone therapy vs placebo treatment of intractable seizures in 294 subjects randomized 2:1 to progesterone or placebo, stratified by catamenial and noncatamenial status. It compared treatments on proportions of ≥50% responders and changes in seizure frequency from 3 baseline to 3 treated menstrual cycles. RESULTS: There was no significant difference in proportions of responders between progesterone and placebo in the catamenial and noncatamenial strata. Prespecified secondary analysis showed that the level of perimenstrual seizure exacerbation (C1 level) was a significant predictor of responders for progesterone but not placebo. With increasing C1 levels, responders increased from 21% to 57% with progesterone vs 19% to 20% with placebo. Reductions in seizure frequency correlated with increasing C1 levels for progesterone but not placebo, progressing from 26% to 71% for progesterone vs 25% to 26% for placebo. A prespecified clinically important separation between progesterone and placebo responders (37.8% vs 11.1%; p = 0.037) was realized among 21.4% of women who had C1 level ≥3. CONCLUSION: There was no difference in the primary outcome of ≥50% responder rates between progesterone vs placebo for catamenial or noncatamenial groups. Post hoc findings suggest that the level of perimenstrual seizure exacerbation is a significant predictor of responder rate with progesterone and that progesterone may provide clinically important benefit for a subset of women with perimenstrually exacerbated seizures. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that cyclic progesterone is ineffective in women with intractable partial epilepsy. Post hoc analysis identified a subset of women with higher levels of perimenstrual seizure exacerbation that were responsive to treatment.

Value of ductal obstruction sign in the differentiation of benign and malignant breast lesions at MR imaging.

PURPOSE: MR-Mammography (MRM) is regarded as the most sensitive method for detection of breast cancer without a broad consensus on specificity. There is room for improvement of the existing ACR BIRADS lexicon by adding new and specific descriptors. Dilated ducts have been described in association with papillomas. However, the differential diagnostic value of this finding has not been investigated yet. MATERIALS AND METHODS: 316 consecutive patients, undergoing histopathologic workup after MR-Mammography were included in this prospective, ethical review board approved study. Two blinded radiologists rated the images in consensus. Ductal obstruction was defined as dilated liquid filled ducts proximal an enhancing lesion. Sensitivity, specificity as well as positive and negative likelihood ratio (LR+, LR-) were calculated. RESULTS: Dilated ducts were found in 60 cases (19%), 20 of these showed an association with enhancing lesions and were categorized as ductal obstruction (6.3%). Malignancy was found in two cases (one invasive ductal carcinoma and one DCIS) and benign tissue in 18 cases (15 papillomas). The difference of ductal obstruction between these groups was found to be highly significant in two-sided Fisher's exact test (p<0.001). Because of the clear association with benign lesions, benign lesions showing ductal obstruction were characterized as true positive findings. Therefore, following diagnostic parameters were calculated: sensitivity 15.4%, specificity 99.0%, LR+ 15.3, LR- 0.9. DISCUSSION: If ductal obstruction is found to be positive, the associated lesion is most likely benign. Therefore, though a rare finding, this descriptor should be taken into account for improved lesion differentiation.

Can color-coded parametric maps improve dynamic enhancement pattern analysis in MR mammography?

PURPOSE: Post-contrast enhancement characteristics (PEC) are a major criterion for differential diagnosis in MR mammography (MRM). Manual placement of regions of interest (ROIs) to obtain time/signal intensity curves (TSIC) is the standard approach to assess dynamic enhancement data. Computers can automatically calculate the TSIC in every lesion voxel and combine this data to form one color-coded parametric map (CCPM). Thus, the TSIC of the whole lesion can be assessed. This investigation was conducted to compare the diagnostic accuracy (DA) of CCPM with TSIC for the assessment of PEC. MATERIALS AND METHODS: 329 consecutive patients with 469 histologically verified lesions were examined. MRM was performed according to a standard protocol (1.5 T, 0.1 mmol/kgbw Gd-DTPA). ROIs were drawn manually within any lesion to calculate the TSIC. CCPMs were created in all patients using dedicated software (CAD Sciences). Both methods were rated by 2 observers in consensus on an ordinal scale. Receiver operating characteristics (ROC) analysis was used to compare both methods. RESULTS: The area under the curve (AUC) was significantly (p=0.026) higher for CCPM (0.829) than TSIC (0.749). The sensitivity was 88.5% (CCPM) vs. 82.8% (TSIC), whereas equal specificity levels were found (CCPM: 63.7%, TSIC: 63.0%). CONCLUSION: The color-coded parametric maps (CCPMs) showed a significantly higher DA compared to TSIC, in particular the sensitivity could be increased. Therefore, the CCPM method is a feasible approach to assessing dynamic data in MRM and condenses several imaging series into one parametric map.

Laterality and location influence catamenial seizure expression in women with partial epilepsy.

OBJECTIVE: The temporal distribution of seizures in women with localization-related epilepsy occurs periodically according to a model "clock" with the peak phase of occurrence corresponding to menstrual onset. The location and laterality of the epileptic lesion as well as patient age may affect periodicity. METHODS: Baseline data from seizure and menstrual diaries of approximately 3 months duration were obtained from 100 women enrolled in a trial of hormonal therapy for localization-related epilepsy. Durations of individual cycles were normalized to a common menstrual phase and period. Normalized data were then combined to create distributions evaluated by localization (lobar: temporal [TL], extratemporal [XL], multifocal [MF], unknown), lateralization (left, right, bilateral, unknown), and age. Distributions were evaluated with analysis of variance (ANOVA) and curve-fitted by nonlinear least squares cosinor analysis. RESULTS: A total of 71 patients had TL (left = 25, right = 29, bilateral = 17), 10 XL, 14 MF, and 5 unknown seizure foci. XL and MF seizures occurred randomly across the 28-day cycle. TL seizures (left = 875, right = 706) occurred nonrandomly (ANOVA p = 0.0003) and cyclically with peak occurrence near onset of menses ([value +/- SD] peak = 1.6 +/- 2.3 days, period = 27.0 days). Left-side TL seizures peaked cyclically at onset of menses (ANOVA p = 0.04, peak = 0.0 +/- 3.0 days, period = 30 days); right-side TL seizures occurred randomly. Age did not have a cyclical effect. Women below the median age had a significantly higher seizure rate than those above the median age. CONCLUSION: Circalunar rhythms of seizures in women, and therefore, possibly strategies of hormonal treatments of catamenial epilepsy, vary with the neuroanatomic substrate of the seizure focus.

Valproate and lamotrigine level variation with menstrual cycle phase and oral contraceptive use.

OBJECTIVE: To determine whether 1) combined oral contraceptive (COC) use affects serum levels of valproate (VPA) as well as lamotrigine (LTG) and 2) the naturally occurring high (mid-luteal) and low (early-mid follicular) reproductive steroid level phases of the menstrual cycle might affect antiepileptic drug levels as well. METHODS: This investigation compared serum antiepileptic drug levels at two timepoints during a single menstrual cycle in four groups of women with epilepsy: 12 on VPA, 12 on VPA plus COC (VPA-COC), 12 on LTG, and 12 on LTG plus COC (LTG-COC). RESULTS: Both VPA and LTG levels were lower (p < 0.01) on active COC than on inactive pill with median declines of 23.4% for the VPA-COC group and 32.6% for the LTG-COC group. Serum LTG levels showed a notable but not significant 31.3% median decline during the mid-luteal phase compared to the early-mid follicular phase in the non-COC group. The non-COC valproate group showed the least change of any group between the two measured timepoints with a decline of 8.3% (p = NS). CONCLUSIONS: The findings suggest that valproate (VPA), like lamotrigine (LTG), has substantially and significantly lower serum levels while women take active combined oral contraceptives as compared to inactive pills. Larger sample sizes will be required to determine whether LTG levels may drop significantly also during the luteal (high steroid) phase of natural menstrual cycles and whether VPA levels may show greater stability in levels across the phases of the menstrual cycle.

Dentinal sensitivity: a natural mineral dietary supplement study.

The purpose of the investigation was to determine the effect of drinking a natural mineral dietary supplement (NMDS) on gingival health and dentinal hypersensitivity. The NMDS product was from a geothermal source and contained 3.6 mg l(-1) of fluoride and other minerals. Sample selection included subjects with gingival inflammation and sensitivity as well as screening for exclusion factors. A double-blind randomized parallel approach was used. The investigation was a quasi-experimental pre/post-test design. The experimental group ingested and swished twice a day with the NMDS (1 l) and the control group followed the same regimen with a placebo containing de-ionized water (DIW). Clinical measurements of gingival inflammation and dentinal sensitivity were taken at baseline, 4 and 8 weeks. Gingival inflammation was measured using the Gingival Index. Dentinal hypersensitivity was measured using a tactile stimulus and an evaporative stimulus. After each stimulus was applied, the subjects rated the amount of discomfort on a visual analogue scale from 0 to 10. Each set of data was analysed using anova and a post hoc probing technique to determine within- and between-group differences (P = 0.05). The experimental and control groups (n = 70) experienced a statistically significant decrease in tactile and evaporative sensitivity scores over time; however, the between-group differences were not significant. The gingival inflammation data were not statistically significant with regard to the within- and between-group differences. Therefore the NMDS and DIW were equally effective in reducing dentinal hypersensitivity and neither product effectively reduced gingival inflammation.

Evaluation of a mass mailing recruitment strategy to obtain a community sample of women for a clinical trial of an incontinence prevention intervention.

OBJECTIVES: Questions exist about using mass mailings to recruit representative samples to participate in clinical trials. The MESA Prevention Study (Medical, Epidemiologic and Social Aspects of Aging), a randomized controlled clinical trial to prevent urinary incontinence (UI), utilized a mass mailing recruitment procedure to recruit a representative sample of women to participate in a behavioral modification program. This paper seeks to expand the literature of mass mailing recruitment strategies for prevention studies by describing the procedures used to recruit healthy, continent, post-menopausal women aged 55-80 years. METHODS: Sociodemographic data collected from recruited subjects is compared with on-line national census data to evaluate the representativeness of the sample recruited from a purchased mailing list. RESULTS: The mass mailing procedure resulted in 3.3% positive response. Of those that returned a positive response, 37.6% were deemed eligible at first screening. Comparisons of study demographic data with state and county census data indicate that the sample obtained was representative of the communities. CONCLUSIONS: The mass mailing strategy was an effective means of recruiting a representative sample of women, aged 55-80. Short falls and recommendations for successful community sample recruitment strategies for clinical trials in older adult women are elaborated upon.

Differential effects of antiepileptic drugs on sexual function and hormones in men with epilepsy.

OBJECTIVE: To compare sexual function and reproductive hormone levels among men with epilepsy who took various antiepileptic drugs (AEDs), untreated men with epilepsy, and normal controls. METHODS: Subjects were 85 men with localization-related epilepsy (25 on carbamazepine [CBZ], 25 on phenytoin [PHT], 25 on lamotrigine [LTG], and 10 untreated for at least 6 months [no AED]) and 25 controls. Sexual function scores (S-scores), hormone levels (bioactive testosterone, estradiol), hormone ratios (bioactive testosterone/bioactive estradiol), and gonadal efficiency (bioactive testosterone/luteinizing hormone) were compared among the five groups. RESULTS: S-scores, bioactive testosterone levels, bioactive testosterone/bioactive estradiol, and bioactive testosterone/luteinizing hormone were significantly greater in the control and LTG groups than in the CBZ and PHT groups. Sex hormone binding globulin was significantly higher in the CBZ and PHT groups than in all other groups. S-scores were below the control range in 20% of the men with epilepsy, including 32.0% on CBZ, 24% on PHT, 20% on no AEDs, and 4% on LTG (chi2: p = 0.08 for all four groups; chi2: p = 0.02 for the three AED groups). Bioactive testosterone was below the control range in 28.2%, including 48% on CBZ, 28% on PHT, 20% on no AEDs, and 12% on LTG (chi2: p = 0.02). Among men with epilepsy who had low S-scores, 70.6% had bioactive testosterone levels below the control range as compared to 17.6% among men with normal S-scores (chi2: p < 0.0001). Among men with epilepsy who had abnormally low bioactive testosterone, 50.0% had low S-scores; among men with normal bioactive testosterone, 8.2% had low S-scores (chi2: p < 0.0001). Bioactive testosterone decline with age was significantly greater among men with epilepsy than among controls and notably greater in the CBZ and PHT groups than in the LTG and untreated groups. CONCLUSIONS: Sexual function, bioavailable testosterone levels, and gonadal efficiency in men with epilepsy who took lamotrigine were comparable to control and untreated values and significantly greater than with carbamazepine or phenytoin treatment.

The Aging, Demographics, and Memory Study: study design and methods.

OBJECTIVE: We describe the design and methods of the Aging, Demographics, and Memory Study (ADAMS), a new national study that will provide data on the antecedents, prevalence, outcomes, and costs of dementia and "cognitive impairment, not demented" (CIND) using a unique study design based on the nationally representative Health and Retirement Study (HRS). We also illustrate potential uses of the ADAMS data and provide information to interested researchers on obtaining ADAMS and HRS data. METHODS: The ADAMS is the first population-based study of dementia in the United States to include subjects from all regions of the country, while at the same time using a single standardized diagnostic protocol in a community-based sample. A sample of 856 individuals age 70 or older who were participants in the ongoing HRS received an extensive in-home clinical and neuropsychological assessment to determine a diagnosis of normal, CIND, or dementia. Within the CIND and dementia categories, subcategories (e.g. Alzheimer's disease, vascular dementia) were assigned to denote the etiology of cognitive impairment. CONCLUSION: Linking the ADAMS dementia clinical assessment data to the wealth of available longitudinal HRS data on health, health care utilization, informal care, and economic resources and behavior, will provide a unique opportunity to study the onset of CIND and dementia in a nationally representative population-based sample, as well as the risk factors, prevalence, outcomes, and costs of CIND and dementia.

[The use of in-situ hybridization for the detection of Brachyspira spp. in pigs]. / Einsatz der in situ Hybridisierung zum Nachweis von Brachyspira spp. beim Schwein.

Diagnosis of Brachyspira infections in swine and the differentiation of the involved bacteria is time-consuming and in most cases unsatisfactory. Detecting Brachyspira directly in the damaged Brachyspira of the large intestine could provide a direct correlation between histological lesionsa and bacterial growth. In this study we investigated whether in-situ hybridization (ISH) with a digoxigenin-labeled RNA-probe is a suitable method for detecting Brachyspira in the mucosa of the large intestine. Formalin-fixed and paraffin-embedded tissue sections of the large intestine from 78 pigs, which showed macroscopic and histological findings of Brachyspira-associated colitis, were stained with hematoxylin and eosin and Warthin-Starry silver impregnation and subjected to ISH. We used a RNA-probe with a length of 334bp, complementary to a part of the 23S rRNA of all members of the genus Brachyspira. All sections were treated with this anti-sense probe and with a sense control probe. 64 samples (82%) showed clearly positive ISH signals. Thus ISH is a suitable method for detecting Brachyspira directly within the lesions of the large intestine. The quantity of Brachyspira identified by ISH was always lower than by Warthin-Starry staining. Whether this reflects lower sensitivity of the ISH technique, or the fact that other bacteria with morphological similarities to Brachyspira were also stained by Warthin-Starry is unknown as yet. The present investigations provide a basis of further research developing specific probes to distinguish between pathogenic and non pathogenic Brachyspira species and probes detecting other bacteria with morphological similarity to Brachyspira.

Out-of-pocket health care expenditures among older Americans with dementia.

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

Predicting nursing home admission: estimates from a 7-year follow-up of a nationally representative sample of older Americans.

This study determines whether prevalence and predictors of nursing home admission changed in the 1990s, during a period of dramatic changes in the service provision for and medical care of chronic impairments. Data from the 1993-2000 surveys of the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a longitudinal and nationally representative sample, were used. Proportional hazard models were used to determine the effects of dementia, physical functioning, clinical conditions, and sociodemographics on the likelihood of nursing home admission. Of the 6,676 respondents, 17% were admitted to a nursing home. Models excluding functional impairment demonstrated significant effects of chronic medical conditions and dementia on the risk of institutionalization. After controlling for functional impairment, dementia still had significant and strong effects on institutionalization but clinical conditions did not, suggesting that the impact of dementia goes beyond its effect on physical functioning. Nursing home admissions did not decrease during the study period, and the impact of dementia on the risk of nursing home admission did not decrease. Interventions for individuals with dementia should impact the behavioral aspects of the condition and slow disease progression in addition to improving physical functioning.