Delaying voiding, limiting fluids, urinary symptoms, and work productivity: A survey of female nurses and midwives

AIM

To examine the relationships between workplace bladder practices, urinary symptoms, and work productivity.

DESIGN

Cross-sectional observational survey.

METHODS

Surveys were distributed June-November 2016 to at least 600 female nurses and midwives at three urban hospitals in New South Wales, Australia. Nurses self-reported restricted workplace access to toilets, delaying voiding, limiting of fluid intakes and urinary symptoms at work. Logistic modelling was used to examine whether nurses' bladder practices impaired their time management, ability to concentrate or perform physical demands.

RESULTS

Of 353 useable surveys, one in five nurses (22.4%; N = 79) reported restricted access to toilets at work, most (77.1%; N = 272) delayed voiding and one in four (26.9%; N = 95) limited fluid intakes to delay voiding at work. Almost half the sample had urinary symptoms at work (46.7%; N = 165); delaying voiding increased the likelihood of impaired mental concentration and limiting fluid intakes increased the likelihood of impaired time management.

CONCLUSION

As workplace access to toilets and related bladder practices are modifiable, associated urinary symptoms and productivity loss may be preventable.

IMPACT

Nurses' often experience restricted accesses to amenities due to job demands and workplace environments. The impact of nurses' poor bladder practices in the workplace is not known. In this study most nurses delayed voiding and many purposefully limited fluid intakes at work. These behaviours impacted a nurse's ability to manage time and/or concentrate at work. Results have implications for nurses' personal health, the design of workplace environments, workforce management, occupational health policy, and patient care.

Iodinated X-ray contrast agents: Photoinduced transformation and monitoring in surface water

Conventional wastewater treatment methods have shown to be unsuitable for a complete elimination of iodinated X-ray contrast agents (ICMs), which have thus been found in wastewater treatment plant (WWTP) effluent and in surface water. Once in the surface water, they could be transformed through different processes and form several transformation products that may need to be monitored as well. To this end, we studied the abatement and transformation of ICMs by combining laboratory experiments with in field analyses. We irradiated different aqueous solutions of the selected pollutants in the presence of TiO₂ as photocatalyst, aimed to promote ICMs degradation and to generate photoinduced transformation products (TPs) similar to those occurring in the environment and effluent wastewater. This experimental strategy has been applied to the study of three ICMs, namely iopromide, iopamidol and diatrizoate. A total of twenty-four, ten, and ten TPs were detected from iopamidol, diatrizoate and iopromide, respectively. The analyses were performed using a liquid chromatography-LTQ-FT-Orbitrap mass spectrometer. The mineralization process and acute toxicity evolution were assessed as well over time and revealed a lack of mineralization for all ICMs and the formation of harmful byproducts. After characterizing these transformation products, WWTP effluent and surface water taken from several branches of the Chicago River were analyzed for ICMs and their TPs. HRMS with MS/MS fragmentation was used as a confirmatory step for proper identification of compounds in water and wastewater samples. All three of ICM were detected in the effluent and surface water samples, while no significant amount of TPs were detected.

A systematic review of prevalence and impact of symptoms of pelvic floor dysfunction in identified workforce groups

AIM

To investigate the prevalence and impact of symptoms of pelvic floor dysfunction in identified workforce groups.

BACKGROUND

Productivity of workforce groups is a concern for ageing societies. Symptoms of pelvic floor dysfunction are associated with ageing and negatively influence psychosocial health. In the general population, lower urinary tract symptoms negatively influence work productivity.

DESIGN

A systematic review of observational studies.

DATA SOURCES

Electronic searches of four academic databases. Reference lists were scanned for relevant articles. The search was limited to English language publications 1990-2014.

REVIEW METHODS

The Centre for Reviews and Dissemination procedure guided the review method. Data extraction and synthesis was conducted on studies where the workforce group was identified and the type of pelvic floor dysfunction defined according to accepted terminology. Quality appraisal of studies was performed using a Joanna Briggs Institute critical appraisal tool.

RESULTS

Twelve studies were identified of variable quality, all on female workers. Nurses were the most frequently investigated workforce group and urinary incontinence was the most common subtype of pelvic floor dysfunction examined. Lower urinary tract symptoms were more prevalent in the studied nurses than related general populations. No included study investigated pelvic organ prolapse, anorectal or male symptoms or the influence of symptoms on work productivity.

CONCLUSION

Lower urinary tract symptoms are a significant issue among the female nursing workforce. Knowledge of the influence of symptoms on work productivity remains unknown. Further studies are warranted on the impact of pelvic floor dysfunction subtypes in workforce groups.

Scoping review of adherence promotion theories in pelvic floor muscle training - 2011 ICS state-of-the-science seminar research paper i of iv

AIMS

This paper, the first of four emanating from the International Continence Society's 2011 State-of-the-Science Seminar on pelvic-floor-muscle training (PFMT) adherence, aimed to summarize the literature on theoretical models to promote PFMT adherence, as identified in the research, or suggested by the seminar's expert panel, and recommends future directions for clinical practice and research.

METHODS

Existing literature on theories of health behavior were identified through a conventional subject search of electronic databases, reference-list checking, and input from the expert panel. A core eligibility criterion was that the study included a theoretical model to underpin adherence strategies used in an intervention to promote PFM training/exercise.

RESULTS

A brief critique of 12 theoretical models/theories is provided and, were appropriate, their use in PFMT adherence strategies identified or examples of possible uses in future studies outlined.

CONCLUSION

A better theoretical-based understanding of interventions to promote PFMT adherence through changes in health behaviors is required. The results of this scoping review and expert opinions identified several promising models. Future research should explicitly map the theories behind interventions that are thought to improve adherence in various populations (e.g., perinatal women to prevent or lessen urinary incontinence). In addition, identified behavioral theories applied to PFMT require a process whereby their impact can be evaluated.

2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 State-of-the-Science Seminar

AIMS

To summarize the findings and "expert-panel" consensus of the State-of-the-Science Seminar on pelvic floor muscle training (PFMT) adherence held prior to the 41st International Continence Society scientific meeting, Glasgow, 2011.

METHODS

Summaries of research and theory about PFMT adherence (based on a comprehensive literature search) were presented by subject experts at the 2011 Seminar to generate discussion and guidance for clinical practice and future research. Supplemental research, post-seminar, resulted in, three review papers summarizing: (1) relevant behavioral theories, (2) adherence measurement, determinants and effectiveness of PFMT adherence interventions, and (3) patients' PFMT experiences. A fourth, reported findings from an online survey of health professionals and the public.

RESULTS

Few high-quality studies were found. Paper I summarizes 12 behavioral frameworks relevant to theoretical development of PFMT adherence interventions and strategies. Findings in Paper II suggest both PFMT self-efficacy and intention-to-adhere predict PFMT adherence. Paper III identified six potential adherence modifiers worthy of further investigation. Paper IV found patient-related factors were the biggest adherence barrier to PFMT adherence.

CONCLUSION

Given the lack of high-quality studies, the conclusions were informed by expert opinion. Adherence is central to short- and longer-term PFMT effect. More attention and explicit reporting is needed regarding: (1) applying health behavior theory in PFMT program planning; (2) identifying adherence determinants; (3) developing and implementing interventions targeting known adherence determinants; (4) using patient-centred approaches to evaluating adherence barriers and facilitators; (5) measuring adherence, including refining and testing instruments; and (6) testing the association between adherence and PFMT outcome.

Assessing the effectiveness of decision aids for decision making in prostate cancer testing: a systematic review

BACKGROUND

Prostate cancer is a leading disease affecting men worldwide. Conflicting evidence within the literature provides little guidance to men contemplating whether or not to be screened for prostate cancer. This systematic review aimed to determine whether decision aids about early detection of prostate cancer improve patient knowledge and decision making about whether to undergo prostate-specific antigen testing.

METHODS

Medline, EMBASE, CINAHL, PsychINFO, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases up until March 2014 were searched. All included randomised controlled trials were assessed for methodological quality. Clinical selection and assessment heterogeneity among studies prevented the pooling of data for meta-analyses. Descriptive analyses of all included studies and comparison were performed.

RESULTS

A total of 13 randomised controlled trials met the inclusion criteria. Significant heterogeneity was present for the design and implementation of decision aids including comparative interventions and outcomes. Eight studies were of a low methodological quality, with the remaining five of medium quality. Improvements in patient knowledge following use of a decision aid were demonstrated by 11 of the 13 included studies. Seven of 10 studies demonstrated a reduction in decisional conflict/distress. Three of four studies demonstrated no difference between a decision aid and information only in reducing decisional uncertainty. Three of five studies demonstrated an increase in decisional satisfaction with use of a decision aid.

CONCLUSIONS

Decision aids increase patient knowledge and confidence in decision making about prostate cancer testing. Further research into effective methods of implementation is needed. Copyright © 2015 John Wiley & Sons, Ltd.

Pelvic floor health: a concept analysis

AIM

To report an analysis of the concept 'pelvic floor health'.

BACKGROUND

'Pelvic floor health' is a term used by multiple healthcare disciplines, yet as a concept is not well defined.

DESIGN

Rodger's evolutionary view was used to guide this analysis.

DATA SOURCES

Academic literature databases and public domain websites viewed via the Internet search engine Google.

REVIEW METHODS

Literature in English, published 1946-July 2014 was reviewed. Websites were accessed in May 2014, then analysed of presentation for relevance and content until data saturation. Thematic analysis identified attributes, antecedents and consequences of the concept.

RESULTS

Based on the defining attributes identified in the analysis, a contemporary definition is offered. 'Pelvic floor health' is the physical and functional integrity of the pelvic floor unit through the life stages of an individual (male or female), permitting an optimal quality of life through its multifunctional role, where the individual possesses or has access to knowledge, which empowers the ability to prevent or manage dysfunction.

CONCLUSION

This analysis provides a definition of 'pelvic floor health' that is based on a current shared meaning and distinguishes the term from medical and lay terms in a complex, multifaceted and often under-reported area of healthcare knowledge. This definition provides a basis for theory development in future research, by focusing on health rather than disorders or dysfunction. Further development of the meaning is required in an individual's social context, to ensure a contemporaneous understanding in a dynamic system of healthcare provision.

[Management of vaginal infection following failure of a probabilistic treatment: is the vaginal swab really useful?]

OBJECTIVE

The aim of this observational national multi-centre study was to describe medical care of vaginal infections resisting a primary probabilistic treatment.

PATIENTS AND METHODS

Two hundred and seventy female patients were included during a 9-month period (from 2013, March 20th to 2013, December 7th) by 155 gynaecologists located throughout France.

RESULTS

All patients were presenting a vulvo-vaginitis episode which started about three weeks ago and which was characterized by leucorrhea (93 % cases), itching (88 % cases) and/or vulvar and/or vaginal irritation (88 % cases). In most cases, this episode was previously treated by a short course of an azole antifungal medication. This treatment was initiated by the patient herself without any doctor's prescription in six out of 10 cases and had no influence on the evolution of the original clinical symptoms. Second line treatments included azole antifungal medications (56 % cases), local fixed combinations (antifungal agent and bactericidal antibiotic) (29 %), metronidazole (9 %), oral antibiotics (7.4 %). At the end of the treatment, 85 % patients recovered from vaginitis symptoms. The recovery rate was 82.6 % for patients who got a bacteriological examination and 87.6 % for patients who were treated without any bacteriological examination. The difference is not statistically significant.

DISCUSSION AND CONCLUSION

These results seem to show that a probabilistic medical care is as effective as (but probably more economical than) a therapeutic strategy guided by the results of further examinations in case of failure of a primary treatment. This conclusion should be confirmed by a medico-economic comparison after randomization.

Normative scores on the Berg Balance Scale decline after age 70 years in healthy community-dwelling people: a systematic review

QUESTIONS

What is the mean Berg Balance Scale score of healthy elderly people living in the community and how does it vary with age? How much variability in Berg Balance Scale scores is present in groups of healthy elderly people and how does this vary with age?

DESIGN

Systematic review with meta-analysis.

PARTICIPANTS

Any group of healthy community-dwelling people with a mean age of 70 years or greater that has undergone assessment using the Berg Balance Scale.

OUTCOME MEASUREMENT

Mean and standard deviations of Berg Balance Scale scores within cohorts of elderly people of known mean age.

RESULTS

The search yielded 17 relevant studies contributing data from a total of 1363 participants. The mean Berg Balance Scale scores ranged from 37 to 55 out of a possible maximum score of 56. The standard deviation of Berg Balance Scale scores varied from 1.0 to 9.2. Although participants aged around 70 years had very close to normal Berg Balance Scale scores, there was a significant decline in balance with age at a rate of 0.7 points on the 56-point Berg Balance Scale per year. There was also a strong association between increasing age and increasing variability in balance (R(2) = 0.56, p < 0.001).

CONCLUSION

Healthy community-dwelling elderly people have modest balance deficits, as measured by the Berg Balance Scale, although balance scores deteriorate and become more variable with age.

Biofeedback for treatment of chronic idiopathic constipation in adults

BACKGROUND

Biofeedback therapy has been used to treat the symptoms of people with chronic constipation referred to specialist services within secondary and tertiary care settings. However, different methods of biofeedback are used within different centres and the magnitude of suggested benefits and comparable effectiveness of different methods of biofeedback has yet to be established.

OBJECTIVES

To determine the efficacy and safety of biofeedback for the treatment of chronic idiopathic (functional) constipation in adults.

SEARCH METHODS

We searched the following databases from inception to 16 December 2013: CENTRAL, the Cochrane Complementary Medicine Field, the Cochrane IBD/FBD Review Group Specialized Register, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsychINFO. Hand searching of conference proceedings and the reference lists of relevant articles was also undertaken.

SELECTION CRITERIA

All randomised trials evaluating biofeedback in adults with chronic idiopathic constipation were considered for inclusion.

DATA COLLECTION AND ANALYSIS

The primary outcome was global or clinical improvement as defined by the included studies. Secondary outcomes included quality of life, and adverse events as defined by the included studies. Where possible, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria.

MAIN RESULTS

Seventeen eligible studies were identified with a total of 931 participants. Most participants had chronic constipation and dyssynergic defecation. Sixteen of the trials were at high risk of bias for blinding. Attrition bias (4 trials) and other potential bias (5 trials) was also noted. Due to differences between study populations, the heterogeneity of the different samples and large range of different outcome measures, meta-analysis was not possible. Different effect sizes were reported ranging from 40 to 100% of patients who received biofeedback improving following the intervention. While electromyograph (EMG) biofeedback was the most commonly used, there is a lack of evidence as to whether any one method of biofeedback is more effective than any other method of biofeedback. We found low or very low quality evidence that biofeedback is superior to oral diazepam, sham biofeedback and laxatives. One study (n = 60) found EMG biofeedback to be superior to oral diazepam. Seventy per cent (21/30) of biofeedback patients had improved constipation at three month follow-up compared to 23% (7/30) of diazepam patients (RR 3.00, 95% CI 1.51 to 5.98). One study compared manometry biofeedback to sham biofeedback or standard therapy consisting of diet, exercise and laxatives. The mean number of complete spontaneous bowel movements (CSBM) per week at three months was 4.6 in the biofeedback group compared to 2.8 in the sham biofeedback group (MD 1.80, 95% CI 1.25 to 2.35; 52 patients). The mean number of CSBM per week at three months was 4.6 in the biofeedback group compared to 1.9 in the standard care group (MD 2.70, 95% CI 1.99 to 3.41; 49 patients). Another study (n = 109) compared EMG biofeedback to conventional treatment with laxatives and dietary and lifestyle advice. This study found that at both 6 and 12 months 80% (43/54) of biofeedback patients reported clinical improvement compared to 22% (12/55) laxative-treated patients (RR 3.65, 95% CI 2.17 to 6.13). Some surgical procedures (partial division of puborectalis and stapled transanal rectal resection (STARR)) were reported to be superior to biofeedback, although with a high risk of adverse events in the surgical groups (wound infection, faecal incontinence, pain, and bleeding that required further surgical intervention). Successful treatment, defined as a decrease in the obstructed defecation score of > 50% at one year was reported in 33% (3/39) of EMG biofeedback patients compared to 82% (44/54) of STARR patients (RR 0.41, 95% CI 0.26 to 0.65). For the other study the mean constipation score at one year was 16.1 in the balloon sensory biofeedback group compared to 10.5 in the partial division of puborectalis surgery group (MD 5.60, 95% CI 4.67 to 6.53; 40 patients). Another study (n = 60) found no significant difference in efficacy did not demonstrate the superiority of a surgical intervention (posterior myomectomy of internal anal sphincter and puborectalis) over biofeedback. Conflicting results were found regarding the comparative effectiveness of biofeedback and botulinum toxin-A. One small study (48 participants) suggested that botulinum toxin-A injection may have short term benefits over biofeedback, but the relative effects of treatments were uncertain at one year follow-up. No adverse events were reported for biofeedback, although this was not specifically reported in the majority of studies. The results of all of these studies need to be interpreted with caution as GRADE analyses rated the overall quality of the evidence for the primary outcomes (i.e. clinical or global improvement as defined by the studies) as low or very low due to high risk of bias (i.e. open label studies, self-selection bias, incomplete outcome data, and baseline imbalance) and imprecision (i.e. sparse data).

AUTHORS' CONCLUSIONS

Currently there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of biofeedback for the management of people with chronic constipation. We found low or very low quality evidence from single studies to support the effectiveness of biofeedback for the management of people with chronic constipation and dyssynergic defecation. However, the majority of trials are of poor methodological quality and subject to bias. Further well-designed randomised controlled trials with adequate sample sizes, validated outcome measures (especially patient reported outcome measures) and long-term follow-up are required to allow definitive conclusions to be drawn.

[Multicentric prospective randomized study evaluating the interest of intravaginal electro-stimulation at home for urinary incontinence after prior perineal reeducation. Interim analysis]

OBJECTIVES

Perineal reeducation of stress urinary incontinence is beneficial in 80% of cases. However, patients have to perform self-retraining exercises of the perineal muscles at home, in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of GYNEFFIK(®), a perineal electro-stimulator, during this home-care phase.

PATIENTS AND METHODS

Women with stress urinary incontinence (UI) or with mixed UI (composed predominantly of stress UI) that responded to physiotherapy were included in this study in two parallel groups. The groups followed a self-reeducation program, with or without GYNEFFIK(®) electro-stimulation sessions. The comparison of the two groups was based on the rate of women for whom the benefit of the initial perineal reeducation was maintained (defined as non-worsening ICIQ and Ditrovie scales' score).

RESULTS

According to the protocol, an interim analysis was performed on 95 patients (i.e. almost half of the expected sample size) who had had at least one evaluation under treatment, among which 44 patients had finished the study. The therapeutic benefit of the initial perineal reeducation was maintained in 87.8% of the GYNEFFIK(®) patient group, while it was maintained in 52.2% (P=0.0001) in the usual care group (i.e. who did not use electro-stimulation).

DISCUSSION AND CONCLUSION

Likewise, patient had a more favorable subjective impression when using GYNEFFIK(®) (83.7% versus 60.0% in the usual care group) as they felt that they improved during the study. In the GYNEFFIK(®) group, no increase in symptoms was reported, whereas almost one out of five patients in the usual care group felt that their condition had worsened.

Immobilization of oligonucleotides on crosslinked poly(vinyl alcohol) for application in DNA chips

In biotechnological applications there is an enormeous growth in the development of new miniaturized devices to reduce timescales, cost and amounts of reagents and starting materials. DNA chips represent miniaturized analytical tools that allow the simultaneous detection of different targets for high throughput screening. They consist of a small size support on which DNA probes are in-situ synthezised or immobilized. We present protocols for the effective immobilization of pre-synthezised 16S rRNA oligonucleotides on crosslinked poly(vinyl alcohol) (PVA). The polymeric gel consists of poly(vinyl alcohol) (PVA) crosslinked with poly(allylamin chloride) (PALAM) and monochlortriazinyl-beta-cyclodextrin (beta-CD) at pH 4,6.8,8 and 9. Mechanical characterization of the gels show that the immobilization capacity increases with increasing pH and increasing crosslinking within the gel. We will demonstrate that the hybridization efficiency on PVA chips is superior over commercially available chips based on nylon, nitrocellulose and aminoalkylsilane.

Dizziness after traumatic brain injury: Results from an interview study

BACKGROUND

Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

OBJECTIVE

To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

SETTING

A community brain injury rehabilitation programme and a community access programme for TBI survivors.

METHOD

Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

RESULTS

The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

CONCLUSION

The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.

Dizziness after traumatic brain injury: Overview and measurement in the clinical setting

Traumatic brain injury (TBI) may result in a variety of cognitive, behavioural and physical impairments. Dizziness has been reported in up to 80% of cases within the first few days after injury. The literature was reviewed to attempt to delineate prevalence of dizziness as a symptom, impairments causing dizziness, the functional limitations it causes and its measurement. The literature provides widely differing estimates of prevalence and vestibular system dysfunction appears to be the best reported of impairments contributing to this symptom. The variety of results is discussed and other possible causes for dizziness were reviewed. Functional difficulties caused by dizziness were not reported for this population in the literature and review of cognitive impairments suggests that existing measurement tools for dizziness may be problematic in this population. Research on the functional impact of dizziness in the TBI population and measurement of these symptoms appears to be warranted.

Living with urinary incontinence: a longitudinal study of older women

BACKGROUND

urinary incontinence carries major social burden and considerable costs for health care systems.

OBJECTIVE

the aim of this study was to investigate changes in continence status among a large cohort of older women, and to identify factors associated with incidence of incontinence in later life.

SUBJECTS

participants of the Australian Longitudinal Study of Women's Health (ALSWH), aged 70-75 years in 1996 and who have completed four health surveys over the past 10 years.

METHODS

continence status across four survey periods, spanning 9 years, were defined according to women's reports of 'leaking urine' at each survey. Generalised estimating equation (GEE) models were used in longitudinal analyses of the factors associated with changing continence status over time.

RESULTS

this study presents longitudinal data on the prevalence and incidence of incontinence from a large cohort of older women, over 9 years of follow-up. Over this time, 14.6% (95% CI 13.9-15.3) of the women in the study who had previously reported leaking urine 'rarely' or 'never' developed incontinence, and 27.2% (95% CI 26.2%, 28.3%) of women participating in Survey 4 (S4) in 2005 reported leaking urine 'sometimes' or 'often' at that survey, with women being twice as likely to report incontinence at S4 as they were 6 years earlier. Longitudinal models demonstrated the association between incontinence and dementia (P < 0.001; OR = 2.34; 95% CI 1.64, 3.34), dissatisfaction with physical ability (P < 0.001; OR = 1.70; 95% CI 1.52, 1.89), falls to the ground (P <0.001; OR = 1.23; 95% CI 1.13, 1.33), BMI (P < 0.001; OR = 2.18; 95% CI 1.70, 2.80 for obese), constipation (P < 0.001; OR 1.46; 95% CI 1.34-1.58), urinary tract infection (P < 0.001; OR 2.07; 95% CI 1.89-2.28), history of prolapse (P </= 0.001; OR = 1.53; 95% CI 1.35, 1.74) and prolapse repair (P = 0.002; OR = 1.23; 95% CI 1.08, 1.40). Stroke (P = 0.01), parity (P = 0.017) and hysterectomy (P = 0.026) and number of visits to the general practitioner (P = 0.040) were less strongly associated with incontinence in the final longitudinal model. Incontinence was not significantly associated with area of residence (P = 0.344), education (P = 0.768), smoking (P = 0.055), diabetes (P = 0.072), attending support groups (P = 0.464) or attending social groups (P = 0.022).

CONCLUSION

strong associations between BMI, dysuria and constipation indicate key opportunities to prevent incontinence among older women.

No association between previous Caesarean-section delivery and back pain in mid-aged Australian women: an observational study

QUESTION

Is there an association between Caesarean section and back pain over the longer term?

DESIGN

Secondary analysis of data from the Australian Longitudinal Study on Women's Health.

PARTICIPANTS

The mid-aged cohort of women within the Australian Longitudinal Study on Women's Health aged 54 to 59 years (n = 9146).

OUTCOME MEASURES

Data were included from women who answered the question regarding back pain. Data were extracted on whether they had given birth and, if so, whether it was by Caesarean section. Then, data on confounding variables (such as arthritis, asthma, osteoporosis, hysterectomy, ovaries removed, and repair of prolapsed vagina, bladder or bowel, menopause, smoking) were also extracted.

RESULTS

After adjusting for confounding factors, women who delivered by Caesarean section had the same odds (OR 1.03, 95% CI 0.81 to 1.31) of having back pain as women who had not had a birth.

CONCLUSION

Previous delivery by Caesarean section is not associated with increased back pain in mid-aged Australian women.

Continence promotion for older hospital patients following surgery for fractured neck of femur: pilot of a randomized controlled trial

Evidence suggests that bladder control problems develop or worsen as a result of fractured neck of femur (#NOF) and its subsequent management. The primary aim of this study was to reduce the prevalence and severity of post surgery continence problems among patients, aged from 60-years, undergoing surgery for #NOF, using a best practice "case-management model" multifactorial intervention. Eligible consenting patients admitted with #NOF were randomized to intervention or control group. Self-report questionnaires compared pre-surgery, post surgery, and follow-up continence status between groups. This pilot randomized controlled trial, which included 45 eligible patients aged 60 to 93-years, found no evidence that the intervention was effective in reducing prevalence of post-surgery incontinence in this acute setting. Staff surveys highlighted the need for open communication between the research team and hospital staff. Unclear results were attributed to the small sample size. A central outcome was evidence that intervention to improve continence management for older people post-surgery is imperative. Focused assessment and treatment for those most at risk of incontinence after #NOF would be more acceptable to staff and a more efficient use of resources. A simple screening tool would ensure that those most at risk are detected, and targeted for care.

Urinary stress incontinence and overactive bladder symptoms in older women

Urinary incontinence - the accidental leaking of urine - is a major problem in Australia and has a significant impact on quality of life, affecting the social, psychological, physical and financial aspects of living. The prevalence of urinary incontinence is significantly higher in women than in men. While urine loss itself is a devastating symptom, older women are also likely to suffer lower urinary tract symptoms associated with the overactive bladder syndrome such as urgency, frequency, mixed incontinence and nocturia which are reported more frequently in older women. These symptoms disrupt activities of daily living as well as seriously disturbing sleep and general health status. Conservative nurse interventions have been shown to be effective in the management of these symptoms. Simple assessment tools suitable for use by primary level clinicians and conservative management strategies are discussed within the paper.

[Management strategies for major depressive episodes as a function of initial response to an SSRI or SNRI antidepressant: results of the ORACLE survey]

OBJECTIVE

The main aim of the major depressive episode treatment is to obtain a complete remission. However, partial remission (persistence of residual symptoms) is a frequent outcome of major depressive episodes, concerning approximately half of the patients who were responders to the treatment. An inadequate treatment response after three weeks of treatment is considered by the ANAES recommendations as a potential reason to modify the treatment regimen. The primary objectives of this survey were to describe the therapeutic strategies implemented in subjects treated as outpatients for a major depressive episode following evaluation of the initial response to an SSRI or an SNRI antidepressant and to assess by a naturalistic way the impact of these strategies on the extent of remission at three months. The secondary objective was to determine, by multivariate analysis, others factors able to influence the remission.

METHODS

This prospective observational survey concerned 2 138 patients treated by community psychiatrists (n=582) and presenting a major depressive episode in the context of a recurrent depressive disorder. Patients were assessed at inclusion and at Weeks 3, at Week 6 and at Week 12. Changes in score on the Hamilton Depression Scale (Ham-D) and CGI severity between inclusion and Week 3 and improvement scores were evaluated. The therapeutic strategies after evaluation were described. Remission was defined as a score of 1 or 2 on the CGI-improvement scale; a treatment response at Week 3 was defined as a decrease of at least 50% in the Ham-D score. The physician also provided an overall rating of satisfaction with the treatment at Week 3.

RESULTS

Data from 1 974 patients were analysed. The mean age at inclusion was 42.7 years, 70% of the patients were women; the mean age at first episode was 32.2 years, the average time since the last episode was 3.6 years. The mean Ham-D score at inclusion was 23.6 +/- 5.8. At Week 3, 29.1% of patients were considered treatment responders. The antidepressant dose was subsequently increased in 10.2% of responders compared to 36.3% of non-responders. When the physician rated the treatment response as unsatisfactory, the dose was increased in 56% of cases. At week 12, 83.7% of patients were in remission as defined by the CGI; according to physician judgement, 45.7% were in complete remission and 43.3% in partial remission. According to the literature, the existence of an early response to the treatment predicted a total remission at Week 12 (69.1% of the treatments responders at Week 3 were in complete remission at Week 12, vs 35.7% of the treatments not-responders).

CONCLUSION

These results underline the professional practices in private community psychiatric practice in France. At Week 3, posology increased for only 36.3% of the patients, whereas it is one of the therapeutic strategies recommended by the ANAES. Participating physicians relied on their subjective judgement about initial treatment response when making decisions about treatment strategies rather than by psychometric scores. At Week 3, 29.1% of patients were considered treatment responders according to the change in Ham-D score, compared to 57.3% whose treatment response was considered satisfactory by the physician. The decision to increase the dose was more closely associated with subjective perceptions of satisfaction than with psychometric rating scale scores, despite psychometric evaluation was systematic in the ORACLE survey, what is not the case in usual practice in France, except for clinical research. In addition, this study confirms an important data for the clinician: there is a correlation between early response to the treatment (Week 3) and complete remission at the end of the acute phase of treatment (Week 12).

An evaluation of three community-based projects to improve care for incontinence

The Australian National Continence Management Strategy commissioned the implementation and evaluation of three community-based projects designed to improve care for people with incontinence by improving the detection and treatment of urinary incontinence. Projects were located in demographically diverse areas, overseen by co-operating professional groups with an interest in continence and aimed at facilitating a pathway of care for those with incontinence. Project activities focused on health care provider training and improving local referral networks, as well as raising public awareness. Multifaceted evaluation of each project was designed to inform principles for a national approach to continence care. The evaluation indicated that providers involved in each project became more confident in their ability to manage incontinence, had significantly increased knowledge of issues around incontinence and became more aware of local options for referral. However, there was little evidence that projects achieved an increase in seeking professional help among those with incontinence. From the evaluation, six principles were developed to guide future models of community-based continence care.

Promoting urinary continence in postpartum women: 12-month follow-up data from a randomised controlled trial

A physiotherapist-delivered continence promotion program was recently implemented with postpartum women in Australia. A previous randomised controlled trial demonstrated that the program was effective in promoting pelvic floor exercises and continence at 3 months postpartum. The present study compares pelvic floor exercise frequency and continence status for women in the intervention and 'usual care' control groups at 12 months postpartum. While there was no significant difference in continence status, women in the intervention group were more likely than those in the control group to be practising pelvic floor exercises at adequate frequencies. In turn, continued adherence to pelvic floor exercises at 12 months was predictive of continence at that time. Potential strategies for enhancing women's adherence to pelvic floor exercise regimes during and beyond the postpartum year are discussed.

Fecal incontinence after high-risk delivery

OBJECTIVE

To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum.

METHODS

A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum.

RESULTS

Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms.

CONCLUSION

The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.

Urinary incontinence across the lifespan

AIMS

The objectives of the current study were (1) to measure type and severity of urinary leakage and (2) to investigate the association between these factors and age-related life events and conditions in three groups of Australian women with a history of urinary leakage.

METHODS

Five hundred participants were randomly selected from women in the young (aged 18-22 in 1996), mid-age (45-50), and older (70-75) cohorts of the Australian Longitudinal Study of Women's Health (ALSWH) who had reported leaking urine in the 1996 baseline survey. Details about leaking urine (frequency, severity, situations) and associated factors (pregnancy, childbirth, body mass index [BMI]) were sought through self-report mailed follow-up surveys in 1999.

RESULTS & CONCLUSIONS

Response rates were 50, 83, and 80% in the young, mid-age, and older women, respectively. Most women confirmed that they had leaked urine in the past month, and the majority of these were cases of "mixed" incontinence. Incontinence severity tended to increase with BMI for women of all ages, and increased severity scores were associated with having urine that burns or stings. Additional independent risk factors for increasing incontinence severity were heavy smoking in young women, past or present use of hormone replacement therapy in older women, and BMI and history of hysterectomy in mid-age women.

Women's knowledge, practises, and intentions regarding correct pelvic floor exercises

AIM

Although research has demonstrated the efficacy of pelvic floor exercises (PFXs) for the prevention and treatment of female urinary incontinence (FUI), adherence to PFX regimens is commonly poor. There is some evidence that this finding is in part due to a lack of knowledge about how to perform PFXs correctly and misconceptions about the required frequency and duration of PFX regimens.

METHODS

By using a sample of 720 postpartum women, this study investigates women's PFX regimens both before and during pregnancy and postpartum.

RESULTS

Findings demonstrated that most women were aware of the required frequency for PFXs (at least every second day): just over half had done them this often during pregnancy and 91% intended to do so postpartum. However, few had done them at this level before pregnancy and less than half knew that PFXs should be carried out indefinitely throughout the lifetime. Moreover, only two thirds were confident that they were doing PFXs correctly.

CONCLUSION

The findings suggest that, despite good knowledge of the required frequency of PFXs, few women practise them regularly over their lifetime, many apparently perceiving PFXs as relevant only to the childbirth years. Implications for health professionals in addressing these gaps in women's knowledge and practises are discussed.

Acceptability of a urinary continence promotion programme to women in postpartum

OBJECTIVE

To assess the acceptability to postpartum women of a physiotherapist-delivered urinary continence promotion programme.

DESIGN

A survey of women participating in a randomised controlled trial where women received the intervention (which involved training in pelvic floor exercises and incorporated adherence-enhancing strategies) or usual postpartum care.

SETTING

Postpartum wards of three tertiary teaching hospitals in the Hunter Region, NSW, Australia.

SAMPLE

Women were eligible to participate in the trial if they had a forceps/ventouse assisted delivery and/or delivered a higher birthweight baby (> or =4000 g). This study is based primarily on data obtained for 348 women in the intervention group.

METHODS

Baseline hospital-based interview; eight-week follow up appointment with physiotherapist; three-month follow up telephone interview.

MAIN OUTCOME MEASURES

Comparative dropout rates for intervention and control groups; reasons for non-participation; attendance at hospital follow up; self-reported acceptability of and embarrassment about per vaginum examination; utilisation and perceived usefulness of intervention components; self-reported adherence with recommended pelvic floor exercise regime.

RESULTS

There was no significant difference in dropouts between intervention (5.9%) and control groups (6.3%). Only 14% of women gave not wanting the per vaginum assessments as their main reason for not participating in the study. Eighty-eight percent of women participated in the eight-week postpartum follow up visit with the physiotherapist, with two-thirds of these women attending the hospital for this; 72.2% of women reported no embarrassment, and 22.5% just a little embarrassment about per vaginum assessment. The information components of the intervention were well received. At the eight-week follow up visit, 83.9% reported performing pelvic floor exercises at adequate frequency.

CONCLUSIONS

The postpartum period provides an ideal opportunity for pelvic floor muscle testing and the delivery of continence promotion advice.

Factors related to thumb pain in physiotherapists

The aim of this study was to determine whether differences exist between physiotherapists with work-related thumb pain and physiotherapists without thumb pain. Twenty-four physiotherapists with work-related thumb pain (Pain Group) and 20 physiotherapists without thumb or wrist pain (Non-pain Group), who were working at least 20 hours per week in an outpatient musculoskeletal setting, were compared on a number of attributes: generalised joint laxity, hand and thumb strength, height, weight, working environment, hand position and force applied during mobilisation, mobility at individual thumb joints, extent of osteoarthritis at the thumb and radial-sided wrist joints, and demographic data including age, gender and years of experience. All physiotherapists in the Pain Group reported their thumb pain was related to and initially caused by the performance of manual techniques, and 88% had altered their manual techniques because of pain in the thumb. There was extreme variability in hand position and force applied during mobilisation, and a slightly high prevalence of osteoarthritis (22.7%) considering the mean age of the total sample (38.6 years). Statistically significant differences between groups included increased right carpometacarpal joint laxity (6.4%, 95% CI 0.19 to 12.6), decreased right tip pinch strength (0.84 kg, 95% CI 0.01 to 1.68), and lower body mass index (2.0, 95% CI 0.11 to 3.9) for the Pain Group. Other factors were not statistically different between groups. These results indicate that work-related thumb pain affects physiotherapists ability to administer manual treatments, and suggest that decreased stability and strength of the thumb may be associated with work-related thumb pain.

Managing urinary incontinence across the lifespan

In the 1996 baseline surveys of the Australian Longitudinal Study of Women's Health (ALSWH), 36.1% of mid-age women (45-50) and 35% of older women (70-75) reported leaking urine. This study aimed to investigate (a) the range of self-management strategies used to deal with urinary incontinence (UI); (b) the reasons why many women who report leaking urine do not seek help for UI; and (c) the types of health professionals consulted and treatment provided, and perceptions of satisfaction with these, among a sample of women in each age group who reported leaking urine "often" at baseline. Five hundred participants were randomly selected from women in each of the mid-age and older cohorts of the ALSWH who had reported leaking urine "often" in a previous survey. Details about UI (frequency, severity, and situations), self-management behaviors and help-seeking for UI, types of health professional consulted, recommended treatment for the problem, and satisfaction with the service provided by health care professionals and the outcomes of recommended treatments were sought through a self-report mailed follow-up survey. Most respondents had leaked urine in the last month (94% and 91% of mid-age and older women, respectively), and 72.2% and 73.1% of mid-aged and older women, respectively, had sought help or advice about their UI. In both age groups, the likelihood of having sought help significantly increased with severity of incontinence. The most common reasons for not seeking help were that the women felt they could manage the problem themselves or they did not consider it to be a problem. Many women in both cohorts had employed avoidance techniques in an attempt to prevent leaking urine, including reducing their liquid consumption, going to the toilet "just in case," and rushing to the toilet the minute they felt the need to.

Promoting urinary continence in women after delivery: randomised controlled trial

OBJECTIVES

To test the effectiveness of a physiotherapist delivered intervention designed to prevent urinary incontinence among women three months after giving birth.

DESIGN

Prospective randomised controlled trial with women randomised to receive the intervention (which entailed training in pelvic floor exercises and incorporated strategies to improve adherence) or usual postpartum care.

SETTING

Postpartum wards of three tertiary teaching hospitals in the Hunter region, New South Wales, Australia.

PARTICIPANTS

Women who had forceps or ventouse deliveries or whose babies had a high birth weight (> or =4000 g), or both-676 (348 in the intervention group and 328 in the usual care group) provided endpoint data at three months.

MAIN OUTCOME MEASURES

Urinary incontinence at three months measured as a dichotomous variable. The severity of incontinence was also measured. Self report of the frequency of performance of pelvic floor exercises was recorded.

RESULTS

At three months after delivery, the prevalence of incontinence in the intervention group was 31.0% (108 women) and in the usual care group 38.4% (125 women); difference 7.4% (95% confidence interval 0.2% to 14.6%, P=0.044). At follow up significantly fewer women with incontinence were classified as severe in the intervention group (10.1%) v (17.0%), difference 7.0%, 1.6% to 11.8%). The proportions of women reporting doing pelvic floor exercises at adequate levels was 84% (80% to 88%) for the intervention group and 58% (52% to 63%) for the usual care group (P=0.001).

CONCLUSIONS

The intervention promoting urinary continence reduced the prevalence of urinary incontinence after giving birth, particularly its severity, and promoted the performance of pelvic floor exercises at adequate levels; both continence and adherence to the programme were measured at three months after delivery in women who had forceps or ventouse deliveries or babies weighing 4000 g or more.

[Epidemiology and management of suspected pneumonia in nursing home residents]

OBJECTIVE

We conducted a descriptive epidemiology study to examine the conditions of management of infectious lung disease in institutionalized elderly populations (population profile, diagnostic and therapeutic modalities) and to analyze the general and mental consequences in terms of independence (impact of the infectious event on the subject's life style).

PATIENTS AND METHODS

A pragmatic survey was conducted by a multicentric observatory composed of 573 general practitioners, practicing in nursing homes. The series included 1790 patients aged over 70 years and residing in nursing homes who developed infectious lung disease over a 10-month period. The MMSE score was used to assess mental status and the Barthel index to assess functional handicap. Each patient was evaluated at the time of the final diagnosis (prescription of an antibiotic or decision for hospitalization) and at most 3 days after the end of this treatment or at discharge from hospital.

RESULTS

The elderly population (84 +/- 7 years) was predominantly composed of women. The patients were treated for an acute respiratory infection considered in 30% of the cases to be acute lobar pneumonia. Subgroups of patients were identified for analysis: death (3.7%), x-ray confirmation of the diagnosis (11.5%), hospitalized patients (10.2%). In addition to major deterioration of the general health status, a consequence of the infection more than of the severity of the respiratory symptoms, the development of an acute episode coincided with reduced intellectual functions and onset of a state of confusion. In 70% of the cases, this resulted in a loss of independence of variable importance--simple difficulty for moving around to major functional handicap. The infectious episode was cured or improved (persistence of minor signs not requiring specific treatment) in 94.3% of the cases with appropriate antibiotics: single-drug regimen in 93.7% give per os (75%) or intravenously (25%) using aminopenicillin (with or without a beta lactamase inhibitor) in 80% of the cases. Antibiotic treatment was associated with physical therapy in more than half the cases, and with general conticosteroids in 40%. The treatment scheme was modified in 9.4% of the cases (change of antibiotic in 6%).

CONCLUSION

This survey confirms the high risk related to general conditions in elderly institutionalized patients who develop respiratory infection. More than the infection itself, the rapid degradation of the general health status, or decompensation of comorbid states can create life-threatening situations or favor the development of irreversible handicaps.

Three-dimensional structure of the Hospital Anxiety and Depression Scale in a large French primary care population suffering from major depression

Few studies have been specifically carried out to characterize the dimensional structure of the Hospital Anxiety and Depression Scale (HADS) and those that have, have yielded contradictory results. We have examined the factor structure and sensitivity to change of the HADS in a large French outpatient primary care population treated with sertraline for major depression (DSM-IV criteria). Factor analysis of the HADS was performed in 2669 outpatients and in subsamples using a principal component procedure with Varimax rotation. Concurrent change sensitivity of the HADS was compared with that for the Hamilton Depression Rating Scale (HDRS) after at least 45 days of sertraline treatment. Three distinct factors emerged from the HADS factor analysis: a "depression" factor and two separate anxiety subscales: "psychic anxiety" and "psychomotor agitation" whose mean reductions in scores from baseline were significantly correlated (0.36-0.45) with the reduction of the HDRS baseline score. These new data provide support for the use of the HADS's three-dimensional structure to measure improvement of selected symptoms of anxiety during antidepressant therapy.

The development of a physiotherapy continence promotion program using a customer focus

Health promotion programs provide information, education for health and opportunity for the development of the skills that people need to make healthy choices. The current climate of health care practice also directs its focus to the needs and wants of the health care consumers. This entails active input from the target group. The present study used focus groups in an attempt to ensure input from women in early postpartum into the development of a postpartum continence promotion program. The focus groups revealed anomalies in women's perceived susceptibility to, and knowledge about, urinary incontinence and pelvic floor exercises, while highlighting other areas of need. Focus groups proved an invaluable tool in the development of a more effective physiotherapy continence promotion program.

Economic costs of urinary incontinence in community-dwelling Australian women

OBJECTIVE

To estimate the economic cost of urinary incontinence in community-dwelling Australian women aged 18 years and over for the year 1998.

DESIGN

Extrapolation of data from studies of women with incontinence to the Australian population of women aged 18 years and over in 1998.

MAIN OUTCOME MEASURES

Estimated prevalence of urinary incontinence in 1998, and estimated cost in Australian dollars of resource use and personal costs related to management of incontinence.

RESULTS

An estimated 1835628 community-dwelling women over the age of 18 years had urinary incontinence in 1998. The total annual cost of this urinary incontinence is estimated at $710.44 million, or $387 per incontinent woman, comprising $338.47 million in treatment costs and $371.97 million in personal costs. An estimated 60% of women with incontinence in 1998 were aged 40 years or over. Assuming the prevalence of incontinence remains constant and, allowing for inflation, we project that the total annual cost in 20 years' time will be $1267.85 million, 93% ($1.18 billion) of which will constitute costs associated with women aged over 40 years.

CONCLUSIONS

Urinary incontinence imposes a considerable drain on Australian healthcare resources. More research is needed to understand the magnitude of the problem and potential gains from continence promotion.