A fiducial-based confidence interval for the linear combination of multinomial probabilities.

Across a broad set of applications, system outcomes may be summarized as probabilities in confusion or contingency tables. In settings with more than two outcomes (e.g., stages of cancer), these outcomes represent multinomial experiments. Measures to summarize system performance have been presented as linear combinations of the resulting multinomial probabilities. Statistical inference on the linear combination of multinomial probabilities has been focused on large-sample and parametric settings and not small-sample settings. Such inference is valuable, however, especially in settings such as those resulting from pilot or low-cost studies. To address this gap, we leverage the fiducial approach to derive confidence intervals around the linear combination of multinomial parameters with desirable frequentist properties. One of the original arguments against the fiducial approach was its inability to extend to multiparameter settings. Therefore, the great novelty of this work is both the derived interval and the logical framework for applying the fiducial approach in multiparameter settings. Through simulation, we demonstrate that the proposed method maintains a minimum coverage of 1 - α $1 - \alpha$ , unlike the bootstrap and large-sample methods, at comparable interval lengths. Finally, we illustrate its use in a medical problem of selecting classifiers for diagnosing chronic allograph nephropathy in postkidney transplant patients.

Choosing between the BP and BN sequential strategies.

Cost and burden of diagnostic testing may be reduced if fewer tests can be applied. Sequential testing involves selecting a sequence of tests, but only administering subsequent tests dependent on results of previous tests. This research provides guidance to choosing between single tests or the believe the positive (BP) and believe the negative (BN) sequential testing strategies, using accuracy (as measured by the Youden Index) as the primary determinant. Approximately 75% of the parameter combinations examined resulted in either BP or BN being recommended based on a higher accuracy at the optimal point. In about half of the scenarios BP was preferred, and the other half, BN, with the choice often a function of the value of the ratio of standard deviations of those without and with disease (b). Large values of b for the first test of the sequence tended to be associated with preference for BN as opposed to BP, while small values of b appear to favor BP. When there was no preference between sequences and/or single tests based on the Youden Index, cost of the sequence was considered. In this case, disease prevalence plays a large role in the selection of strategies, with lower values favoring BN and sometimes higher values favoring BP. The cost threshold for the sequential strategy to be preferred over a single, more accurate test, was often quite high. It appears that while sequential strategies most often increase diagnostic accuracy over a single test, sequential strategies are not always preferred.

High-Frequency Ultrasound: Description of Sacral Tissue Characteristics in Healthy Adults.

OBJECTIVES: The purpose of this study was to describe selected sacral tissue characteristics in a convenience sample of healthy volunteer subjects. DESIGN: Descriptive. SAMPLE AND SETTING: Fifty healthy volunteers in a clinical learning center in a school of nursing. METHODS: Sacral scans were obtained using a 20-MHz ultrasound scanning system in 3 positions: prone and 60° and 90° side-lying from the back. The images were analyzed by software in the ultrasound program using quantitative parameters of dermal thickness and density (dermal median intensity and derived number of low-echogenic pixels to total pixels [LEP:TP] ratio). RESULTS: In general, average values were as follows: dermal thickness between 2.32 and 2.65 mm; median pixel intensity between 102 and 112; and the LEP:TP ratio between 0.39 and 0.56. There were significant differences in sacral tissue characteristics between measures of thickness and dermal density (median intensity and LEP:TP ratio) by subject side-lying position (60° and 90°) versus prone position, with all P values less than .0001. CONCLUSIONS: Overall, the ranges were consistent across measures of thickness and dermal density except for systematic differences between side-lying and prone positions. When comparing thickness, median intensity, or LEP:TP ratio, it is important to report subject position. To best recognize tissue inflammation indicative of pressure injuries before surface changes are seen, it is useful to understand healthy high-frequency ultrasound sacral tissue characteristics. It is anticipated that quantitative assessment of dermal thickness, density, and LEP:TP ratio could help identify individuals with incipient pressure injury.

A nonparametric fiducial interval for the Youden index in multi-state diagnostic settings.

The Youden index is a commonly employed metric to characterize the performance of a diagnostic test at its optimal point. For tests with three or more outcome classes, the Youden index has been extended; however, there are limited methods to compute a confidence interval (CI) about its value. Often, outcome classes are assumed to be normally distributed, which facilitates computational formulas for the CI bounds; however, many scenarios exist for which these assumptions cannot be made. In addition, many of these existing CI methods do not work well for small sample sizes. We propose a method to compute a nonparametric interval about the Youden index utilizing the fiducial argument. This fiducial interval ensures that CI coverage is met regardless of sample size, underlying distributional assumptions, or use of a complex classifier for diagnosis. Two alternate fiducial intervals are also considered. A simulation was conducted, which demonstrates the coverage and interval length for the proposed methods. Comparisons were made using no distributional assumptions on the outcome classes and for when outcomes were assumed to be normally distributed. In general, coverage probability was consistently met, and interval length was reasonable. The proposed fiducial method was also demonstrated in data examining biomarkers in subjects to predict diagnostic stages ranging from normal kidney function to chronic allograph nephropathy. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Confidence intervals around Bayes Cost in multi-state diagnostic settings to estimate optimal performance.

A critical feature of diagnostic testing is correctly classifying subjects based upon specified thresholds of some measure. The commonly employed Youden index determines a test's optimal thresholds by maximizing the correct classification rates for a diagnostic scenario. An alternative to the Youden index is the cost function, Bayes Cost (BC). BC determines a test's optimal setting by minimizing the sum of all misclassification rates from the test. Unlike the Youden index, BC can consider a priori costs of all the diagnostic outcomes including class specific misclassifications regardless of the number of classes. Delta method approximate confidence intervals around BC are derived under the assumption of normally distributed classes as a means for quantifying a test's performance and comparing classifiers at their optimal settings in a multi-state diagnostic framework. A simulation study is conducted to demonstrate the performance of the derived confidence intervals that are found to perform well, especially for sample sizes of 50 or larger in each diagnostic class. Finally, the proposed methods are applied to a four-class breast tissue classification problem, where four possible discriminatory features are compared under varying decision cost structures. Using the confidence intervals around BC, the best feature for classification is selected, and the optimal thresholds and their 95% confidence intervals are determined.

Reducing cost in sequential testing: a limit of indifference approach.

In noninferiority studies, a limit of indifference is used to express a tolerance in results such that the clinician would regard such results as being acceptable or 'not worse'. We applied this concept to a measure of accuracy, the Receiver Operating Characteristic (ROC) curve, for a sequence of tests. We expressed a limit of indifference for the range of acceptable sensitivity values and examined the associated cost of testing within this range. In doing so, we generated the minimum cost maximum ROC (MCMROC) curve, which reflects the reduced sensitivity and cost of testing. We compared the MCMROC and its associated cost curve between limits of indifference set to 0.999 [a 0.1% reduction in true positive rate (TPR)], 0.95 (a 5% reduction in TPR), and 1 (no reduction in TPR). The limit of indifference tended to have less of an effect on the MCMROC curves than on the associated cost curves that were greatly affected. Cost was reduced at high false positive rates (FPRs) at higher limit of indifference (0.999) and at small FPRs as the limit of indifference decreased (0.95). These patterns were also observed as applied to sequential strategies used to diagnose diabetes in the Pima Indians.

Secular trends in body composition for children and young adults: the Fels Longitudinal Study.

OBJECTIVES: To determine secular trends by birth decade in body mass index (BMI), waist circumference/height (W/Ht), percent body fat (PBF), and fat-free mass adjusted for height squared (FFM/Ht(2) ) in children and adolescents aged 8-18 years. METHODS: Serial data were analyzed from 628 boys and 591 girls aged 8-18 years who participated in the Fels Longitudinal Study. Subjects were stratified by birth decade from 1960 to 1999. Means and standard deviations were computed for all measurements by birth decade, age, and sex. A repeated-measures analysis of variance was used data to ascertain secular trends separately for boys and girls. RESULTS: Boys and girls born in the 1990s had significantly higher mean BMI, W/Ht, and PBF than did children born in previous decades. Mean FFM/Ht(2) was significantly smaller in boys born in the 1990s than boys of the same age born in earlier decades. No secular trend was noted in FFM/Ht(2) in girls by decade of birth. CONCLUSION: Our analysis of serial data collected over 4 decades confirms the secular trend in childhood BMI previously observed in successive cross-sectional studies. Our analysis discloses significant positive secular trends in W/Ht and PBF in both boys and girls and a significant negative secular trend in FFM/Ht(2) in boys over the last 4 decades of the 20th century. The secular changes presage increases in the prevalence of conditions associated with childhood and adolescent obesity-such as hypertension, glucose intolerance, and dyslipidemia-that may appear as early as the second decade of life.

A longitudinal systems biology analysis of lactulose withdrawal in hepatic encephalopathy.

The pathogenesis of hepatic encephalopathy(HE) is unclear. However gut flora changes, inflammation and neuro-glial injury have been implicated. The aim was to evaluate factors that were associated with HE recurrence after lactulose withdrawal by analyzing the clinical phenotype, stool microbiome and systemic metabolome longitudinally. HE patients on a standard diet who were adherent on lactulose underwent characterization of their phenotype [cognition, inflammatory cytokines, in-vivo brain MR spectroscopy(MRS)], gut microbiome (stool Multitag Pyrosequencing) and metabolome (urine/serum ex-vivo MRS) analysis while on lactulose and on days 2, 14 and 30 post-withdrawal. Patients whose HE recurred post-withdrawal were compared to those without recurrence. We included seven men (53 ± 8 years) who were adherent on lactulose after a precipitated HE episode were included. HE recurred in three men 32 ± 6 days post-withdrawal. In-vivo brain MRS showed increased glutamine+glutamate (Glx) and decreased myoinositol with a reduction in stool Faecalibacterium spp., post-withdrawal. HE recurrence was predicted by poor baseline inhibitory control and block design performance and was associated with a shift of choline metabolism from tri-methylamine oxide formation towards the development of di-methylglycine, glycine and creatinine. This was accompanied by a mixed effect on the immune response (suppressed IL-10 and Th1/Th2/Th17 response). The correlation network showed Prevotella to be linked to improved cognition and decreased inflammation in patients without HE recurrence. We conclude that lactulose withdrawal results in worsening cognition, mixed inflammatory response effect, lowered stool Faecalibacterium and increase in MR-measurable brain Glx. HE recurrence post-lactulose withdrawal can be predicted by baseline cognitive performance and is accompanied by disrupted choline metabolism.

Supportive relationships, self-care confidence, and heart failure self-care.

BACKGROUND: The theory of heart failure (HF) self-care proposes that confidence mediates relationships between social support and self-care behaviors. OBJECTIVE: This study aimed to examine the effects of supportive relationships on self-care behaviors and the mediating effects of self-care confidence in HF outpatients. METHODS: Structural equation modeling (SAS version 9.1, SAS Institute Inc, Cary, North Carolina) was used to examine the influence of supportive relationships and self-care confidence on self-care management and maintenance in a cross-section of patients with HF (n = 97; age = 56 years; 57% men; 45% African American; 55% married). Models included 3 variables characterizing supportive relationships: marital status (1 = currently married, 0 = not currently married), social network size (number of persons available to provide support), and perceived social support (Medical Outcomes Study Social Support Scale). To account for the effects of severity of illness, 2 measures characterizing severity of HF were included: left ventricular ejection fraction and New York Heart Association functional classification of HF. The Self-Care of Heart Failure Index (version 4) was used to measure self-care confidence, management, and maintenance. A consensus of fit indices estimated overall model fit. RESULTS: Initial models fit the data; however, to improve fit and identify the most parsimonious models, 3 nonsignificant paths were removed, and modified models, including only social support and social network size, were proposed and tested. Modified models fit the data well and accounted for 15% in the variance in self-care maintenance (χ(2) P = .29) and 18% of the variance in self-care management (χ(2) P = .631). The indirect effect of social support (ß = 0.37; P = .0004) through self-care confidence (ß = 0.35; P = .0002) on self-care management, in the absence of a significant direct effect, supports the hypothesis that self-care confidence mediates the relationship between social support and self-care management. Social network size had a negative effect on self-care confidence (ß = -0.22; P = .029), but this effect was mediated by self-care confidence (ß = 0.33; P = .0002), which reduced the total negative effects. Self-care confidence was the best predictor of self-care management. In the self-care maintenance model, direct (ß = 0.27; P = .003) and indirect effects of social support (ß = 0.37; P = .0002) on self-care maintenance through self-care confidence (ß = 0.22; P = .001) attenuated negative effects of social network size (ß = -0.22; P = .0145). Social support was the best predictor of self-care maintenance. CONCLUSIONS: Findings support the positive influence of social support on self-care behaviors. Self-care confidence mediated the relationship between social support and self-care behaviors and had direct influence on these behaviors as well. This suggests that self-care confidence and self-care behaviors can be enhanced by improving the quality of social support.

Persistence of cognitive impairment after resolution of overt hepatic encephalopathy.

BACKGROUND & AIMS: In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE). METHODS: Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE. RESULTS: In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing. CONCLUSIONS: In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.

Accuracy and cost comparison in medical testing using sequential testing strategies.

The practice of sequential testing is followed by the evaluation of accuracy, but not by the evaluation of cost. This paper focuses on three logic rules for combining two sequences of tests: believe the positive (BP), which diagnoses disease if any of two tests is positive, believe the negative (BN), which diagnoses disease if any of two tests is negative, and believe the extreme (BE), which diagnoses disease if the first test is positive or, after a first inconclusive test, a second test is positive for disease. Comparisons of these strategies are provided in terms of accuracy using false positive rate, sensitivity pairs that make up the maximum receiver operating characteristic curve, and cost of testing, defined as the proportion of subjects needing two tests to diagnose disease. A method to incorporate the cost of testing into the definition of the optimal operating point is also presented. The performance of the testing strategies is examined with respect to the ratio of standard deviations and the correlation between test results under the bivariate normal assumptions. Under all parameter settings, the maximum receiver operating characteristic curve of the BE strategy never performed worse than the BN and BP strategies; the BE strategy also had the lowest cost. The use of body mass index and plasma glucose concentration to diagnose diabetes in Pima Indians was presented as a real-world application. The optimal operating points found by the BN and BE strategies produce lower false positive rate values than the BP strategy for these data.

Minimal hepatic encephalopathy is associated with motor vehicle crashes: the reality beyond the driving test.

UNLABELLED: Patients with minimal hepatic encephalopathy (MHE) have impaired driving skills, but association of MHE with motor vehicle crashes is unclear. Standard psychometric tests (SPT) or inhibitory control test (ICT) can be used to diagnose MHE. The aim was to determine the association of MHE with crashes and traffic violations over the preceding year and on 1-year follow-up. Patients with cirrhosis were diagnosed with MHE by ICT (MHEICT) and SPT (MHESPT). Self and department-of-transportation (DOT)-reports were used to determine crashes and violations over the preceding year. Agreement between self and DOT-reports was analyzed. Patients then underwent 1-year follow-up for crash/violation occurrence. Crashes in those with/without MHEICT and MHESPT were compared. 167 patients with cirrhosis had DOT-reports, of which 120 also had self-reports. A significantly higher proportion of MHEICT patients with cirrhosis experienced crashes in the preceding year compared to those without MHE by self-report (17% vs 0.0%, P = 0.0004) and DOT-reports (17% vs 3%, P = 0.004, relative risk: 5.77). SPT did not differentiate between those with/without crashes. A significantly higher proportion of patients with crashes had MHEICT compared to MHESPT, both self-reported (100% vs 50%, P = 0.03) and DOT-reported (89% vs 44%, P = 0.01). There was excellent agreement between self and DOT-reports for crashes and violations (Kappa 0.90 and 0.80). 109 patients were followed prospectively. MHEICT patients had a significantly higher future crashes/violations compared to those without (22% vs 7%, P = 0.03) but MHESPT did not. MHEICT (Odds ratio: 4.51) and prior year crash/violation (Odds ratio: 2.96) were significantly associated with future crash/violation occurrence. CONCLUSION: Patients with cirrhosis and MHEICT have a significantly higher crash rate over the preceding year and on prospective follow-up compared to patients without MHE. ICT, but not SPT performance is significantly associated with prior and future crashes and violations. There was an excellent agreement between self- and DOT-reports.

Is laminin gamma-1 a candidate gene for advanced pelvic organ prolapse?

OBJECTIVE: We sought to determine allele frequencies of 3 LAMC1 single nucleotide polymorphisms (SNPs) in Caucasian and African American (AA) women with stage>II pelvic organ prolapse (POP) (cases) and in ethnicity-matched controls with stage

The Relationship between Pet Ownership, Social Support, and Internalizing Symptoms in Students from the First to Fourth Year of College.

Internalizing symptoms are prevalent in students as they enter and complete college. Considering research suggesting mental health benefits of pet ownership, this study explores the relationship between pet ownership, social support (SS), and internalizing symptoms (IS) in a cohort of students across their 4-year college experience. With no differences at college entry, students growing up with pets had greater IS through the fourth year, and greater SS through the third year, than those without pets. Currently living with a pet, gender, SS and personality predicted IS in the fourth year. Females experiencing higher IS in their first year are more likely to live with pets in their fourth year, and fourth year females living with pets or greatly missing absent pets have higher IS than females without pets or missing pets less. Findings suggest a unique relationship between IS in female students and their pet relationships not seen in males.

The effect of fatigue on driving skills in patients with hepatic encephalopathy.

OBJECTIVES: Hepatic encephalopathy, both overt (OHE) and minimal (MHE), is associated with poor quality of life and fatigue. The aim of this study was to define the effect of fatigue on driving skills in MHE and OHE patients. METHODS: Cirrhotics and age/education-matched controls were administered a psychometric battery of tests to diagnose MHE. Cirrhotics with recent OHE on lactulose were also included. All subjects underwent a driving simulation; to assess fatigue, the second half performance was compared with the first half of the simulation. The outcomes were collisions, speeding, road excursions, and center crossings. Actual driving-associated fatigue was assessed by the American Medical Association (AMA) driver survey. RESULTS: A total of 100 cirrhotics (51 MHE, 27 no MHE, and 22 OHE) and 67 controls were included. A significantly higher proportion of OHE and MHE patients admitted to fatigue after actual driving on the AMA survey compared with no MHE patients (P=0.02). All patients who admitted to fatigue and none who denied fatigue on the AMA survey had simulator collisions. Psychometric and simulator performance in treated OHE patients was similarly impaired to MHE patients despite therapy. Within groups, a significant increase in collisions, speeding, and center crossings in the second half (P=0.01) was seen only in MHE patients. CONCLUSIONS: Psychometric and simulator performance in patients with recent OHE on treatment is similarly impaired as that of untreated MHE patients. Simulator performance in MHE worsens over time with fatigue. OHE and MHE patients had a higher rate of actual driving-associated fatigue on the AMA survey, which was significantly predictive of simulator collisions.

Prolonged juvenile States and delay of cardiovascular and metabolic risk factors: the Fels Longitudinal study.

OBJECTIVES: To ascertain the influence of such a prolonged juvenile state on delaying the onset of the metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus later in life. STUDY DESIGN: We define prolongation of a juvenile state as a retarded tempo of growth, determined by the timing of peak height velocity in each subject and relate the retarded tempo of growth to metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus later in life by use of serial data of 237 study participants (119 men and 118 women) enrolled in the Fels Longitudinal study. RESULTS: Children who matured early tended to have greater body mass index, waist circumference, and percent of body fat and were more likely to have adverse cardiovascular risk profiles than children who matured late. The differences in these risk factors between early and late maturers were significant for percent body fat, fasting plasma triglycerides, and fasting plasma insulin. CONCLUSIONS: The analyses disclosed a clear separation between early and late maturers in the appearance of these risk factors in young adulthood.

Additive utility of family history and waist circumference to body mass index in childhood for predicting metabolic syndrome in adulthood.

OBJECTIVE: To determine whether waist circumference (WC) and family history of disease increase the predictive utility of body mass index (BMI) for adult metabolic syndrome (MetS). STUDY DESIGN: A subsample of 161 men and women from the Fels Longitudinal Study with childhood and adulthood measures were analyzed. Using logistic regression, childhood BMI categories (50th, 75th, and 85th percentiles), WC categories (75th and 90th percentiles), and family history of type 2 diabetes mellitus or cardiovascular disease were modeled separately and in combinations to predict adult MetS. Predicted probabilities and c-statistics were compared across models. RESULTS: The addition of family history to BMI improved the predicted probability of adult MetS from 29% to 52% (Deltac-statistic = 0.13). The combination of WC and BMI was more predictive than BMI alone but did not outperform the combination of family history and BMI. In 3 of the 4 models with a combination of family history, WC, and BMI, the predicted probability of adult MetS did not exceed that from the combination of family history and BMI. CONCLUSIONS: Family history of type 2 diabetes or cardiovascular disease is a useful addition to BMI in childhood to predict the future risk of adult MetS.

Predictive ability of childhood metabolic components for adult metabolic syndrome and type 2 diabetes.

OBJECTIVE: To estimate sensitivity, specificity, and positive and negative predictive values of components of the metabolic syndrome (MetS) during childhood for MetS and type 2 diabetes (T2D) in adulthood. STUDY DESIGN: Data from 3 major studies-the Fels Longitudinal Study, the Muscatine Study, and the Princeton Follow-up Study-were combined to examine how thresholds of metabolic components during childhood determine adult MetS and T2D. Available metabolic components examined in the 1789 subjects included high-density lipoprotein, triglyceride levels, glucose, and percentiles for body mass index, waist circumference, triglycerides, and systolic and diastolic blood pressures. Sensitivity, specificity, and positive and negative predictive values for a refined set of component threshold values were examined individually and in combination. RESULTS: Sensitivity and positive predictive values remained low for adult MetS and T2D for individual components. However, specificity and negative predictive values were fairly high for MetS and exceptionally so for T2D. In combination, having 1 or more of the components showed the highest sensitivity over any individual component and high negative predictive value. Overall, specificity and negative predictive values remained high whether considering individual or combined components for T2D. CONCLUSIONS: Sensitivity and positive predictive values on the basis of childhood measures remained relatively low, but specificity and negative predictive values were consistently higher, especially for T2D. This indicates that these components, when examined during childhood, may provide a useful screening approach to identifying children not at risk so that further attention can be focused on those who may be in need of future intervention.

Receptive language outcomes in children after cochlear implantation.

OBJECTIVES: The objectives of the present study were (1) to assess receptive language scores in children after cochlear implantation and compare them with scores in normal hearing children and children with hearing loss that use hearing aids and (2) to determine how demographic factors, such as age of implantation, impact language outcomes. STUDY DESIGN: Case series. SUBJECTS/METHODS: Receptive language scores in children with profound prelingual hearing loss who received cochlear implants between 1996 and 2004 were analyzed. RESULTS: Standardized language assessments were available for 36 children. The average age at implantation was 33 months. The mean language scores for implanted children were within 1 standard deviation of scores of normal hearing individuals. Children with cochlear implants had significantly higher subtest scores (P < 0.05) than children with hearing aids. Children with additional disabilities had significantly (P < 0.05) poorer language performance. CONCLUSIONS: Pediatric cochlear implant recipients acquire receptive language skills that approach those of their hearing peers and exceed those of children with hearing aids.

Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants.

UNLABELLED: The purpose of this study was to examine the knowledge, beliefs, and practices of nursing assistants (NAs) providing oral hygiene care to frail elders in nursing homes, with the intent of developing an educational program for NAs. METHODS: The study occurred in two economically and geographically diverse nursing homes. From a sample size of 202 NAs, 106 returned the 19-item Oral Care Survey. RESULTS: The NAs reported satisfactory knowledge regarding the tasks associated with providing mouth care. The NAs believed that tooth loss was a natural consequence of aging. They reported that they provided mouth care less frequently than is optimal but cited challenges such as caring for persons exhibiting care-resistive behaviors, fear of causing pain, and lack of supplies. CONCLUSION: Nurses are in a powerful position to support NAs in providing mouth care by ensuring that they have adequate supplies and knowledge to respond to resistive behaviors.