The minimum important difference for the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form in women with stress urinary incontinence.

INTRODUCTION: Minimum important difference (MID) estimates the minimum degree of change in an instrument's score that correlates with a patient's subjective sense of improvement. We aimed to determine the MID for the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) using both anchor based and distribution based methods derived using data from the Trial of Midurethral Slings (TOMUS). MATERIALS AND METHODS: Instruments for the anchor-based analyses included the urogenital distress inventory (UDI), incontinence impact questionnaire (IIQ), patient global impression of improvement (PGI-I), incontinence episodes (IE) on 7-day bladder diary, and satisfaction with surgical results. After confirming moderate correlation (r ≥ 0.3) of ICIQ-UI SF and each anchor, MIDs were determined by calculating the difference between the mean instrument scores for individuals with the smallest amount of improvement and with no change. The distribution-based method of MID assessment was applied using effect sizes of 0.2 and 0.5 SD (small to medium effects). Triangulation was used to examine these multiple MID values in order to converge on a small range of values. RESULTS: Anchor-based MIDs range from -4.5 to -5.7 at 12 months and from -3.1 to 4.3 at 24 months. Distribution-based MID values were lower. Triangulation analysis supports a MID of -5 at 12 months and -4 at 24 months. CONCLUSION: The recommended MIDs for ICIQ-UI SF are -5 at 12 months and -4 at 24 months. In surgical patients, ICIQ-UI SF score changes that meet these thresholds can be considered clinically meaningful.

Urinary incontinence management costs are reduced following Burch or sling surgery for stress incontinence.

OBJECTIVE: The objective of the study was to estimate the effect of Burch and fascial sling surgery on out-of-pocket urinary incontinence (UI) management costs at 24 months postoperatively and identify predictors of change in cost among women enrolled in a randomized trial comparing these procedures. STUDY DESIGN: Resources used for UI management (supplies, laundry, dry cleaning) were self-reported by 491 women at baseline and 24 months after surgery, and total out-of-pocket costs for UI management (in 2012 US dollars) were estimated. Data from the 2 surgical groups were combined to examine the change in cost for UI management over 24 months. Univariate and bivariate changes in cost were analyzed using the Wilcoxon signed rank test. Predictors of change in cost were examined using multivariate mixed models. RESULTS: At baseline mean (±SD) age of participants was 53 ± 10 years, and the frequency of weekly UI episodes was 23 ± 21. Weekly UI episodes decreased by 86% at 24 months (P < .001). The mean weekly cost was $16.60 ± $27.00 (median $9.39) at baseline and $4.57 ± $15.00 (median $0.10) at 24 months (P < .001), a decrease of 72%. In multivariate analyses, cost decreased by $3.38 ± $0.77 per week for each decrease of 1 UI episode per day (P < .001) and was strongly associated with greater improvement in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores (P < .001) and decreased 24-hour pad weight (P < .02). CONCLUSION: Following Burch or fascial sling surgery, the UI management cost at 24 months decreased by 72% ($625 per woman per year) and was strongly associated with decreasing UI frequency. Reduced out-of-pocket expenses may be a benefit of these established urinary incontinence procedures.

Treatment status and risk factors for incidence and persistence of urinary incontinence in women.

INTRODUCTION AND HYPOTHESIS: The objective of this analysis was to describe urinary incontinence (UI) incidence and persistence over 5 years in association with treatment status, sociodemographic, medical, and lifestyle factors, in a racially/ethnically diverse population-based female sample. METHODS: The Boston Area Community Health Survey enrolled 3,201 women aged 30-79 years of black, Hispanic, and white race/ethnicity. Five-year follow-up was completed by 2,534 women (conditional response rate 83.4 %), allowing population-weighted estimates of UI incidence and persistence rates. Predictors of UI were determined using multivariate logistic regression models. RESULTS: Incidence of UI at least monthly was 14.1 % and weekly 8.9 %. Waist circumference at baseline and increasing waist circumference over 5-year follow-up were the most robust predictors of UI incidence in multivariate models (P ≤ 0.01). Among 475 women with UI at baseline, persistence was associated with depression symptoms [monthly UI, odds ratio (OR) = 2.39, 95 % confidence interval (CI) 1.14-5.02] and alcohol consumption (weekly UI, OR = 3.51, 95 % CI 1.11-11.1). Among women with weekly UI at baseline, 41.7 % continued to report weekly UI at follow-up, 14.1 % reported monthly UI, and 44.2 % had complete remission. Persistence of UI was not significantly higher (58.2 % vs. 48.0 %, chi-square P = 0.3) among untreated women. Surgical or drug treatment for UI had little impact on estimates for other risk factors or for overall population rates of persistence or remission. CONCLUSIONS: Women with higher gains in waist circumference over time were more likely to develop UI, but waist circumference was not predictive of UI persistence. UI treatments did not affect associations for other risk factors. Additional research on the role of alcohol intake in UI persistence is warranted.

Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults.

OBJECTIVES: To determine the effects of cognitive training on cognitive abilities and everyday function over 10 years. DESIGN: Ten-year follow-up of a randomized, controlled single-blind trial (Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE)) with three intervention groups and a no-contact control group. SETTING: Six U.S. cities. PARTICIPANTS: A volunteer sample of 2,832 persons (mean baseline age 73.6; 26% African American) living independently. INTERVENTION: Ten training sessions for memory, reasoning, or speed of processing; four sessions of booster training 11 and 35 months after initial training. MEASUREMENTS: Objectively measured cognitive abilities and self-reported and performance-based measures of everyday function. RESULTS: Participants in each intervention group reported less difficulty with instrumental activities of daily living (IADLs) (memory: effect size = 0.48, 99% confidence interval (CI) = 0.12-0.84; reasoning: effect size = 0.38, 99% CI = 0.02-0.74; speed of processing: effect size = 0.36, 99% CI = 0.01-0.72). At a mean age of 82, approximately 60% of trained participants, versus 50% of controls (P < .05), were at or above their baseline level of self-reported IADL function at 10 years. The reasoning and speed-of-processing interventions maintained their effects on their targeted cognitive abilities at 10 years (reasoning: effect size = 0.23, 99% CI = 0.09-0.38; speed of processing: effect size = 0.66, 99% CI = 0.43-0.88). Memory training effects were no longer maintained for memory performance. Booster training produced additional and durable improvement for the reasoning intervention for reasoning performance (effect size = 0.21, 99% CI = 0.01-0.41) and the speed-of-processing intervention for speed-of-processing performance (effect size = 0.62, 99% CI = 0.31-0.93). CONCLUSION: Each Advanced Cognitive Training for Independent and Vital Elderly cognitive intervention resulted in less decline in self-reported IADL compared with the control group. Reasoning and speed, but not memory, training resulted in improved targeted cognitive abilities for 10 years.

The Congenital Heart Disease Genetic Network Study: rationale, design, and early results.

Congenital heart defects (CHD) are the leading cause of infant mortality among birth defects, and later morbidities and premature mortality remain problematic. Although genetic factors contribute significantly to cause CHD, specific genetic lesions are unknown for most patients. The National Heart, Lung, and Blood Institute-funded Pediatric Cardiac Genomics Consortium established the Congenital Heart Disease Genetic Network Study to investigate relationships between genetic factors, clinical features, and outcomes in CHD. The Pediatric Cardiac Genomics Consortium comprises 6 main and 4 satellite sites at which subjects are recruited, and medical data and biospecimens (blood, saliva, cardiovascular tissue) are collected. Core infrastructure includes an administrative/data-coordinating center, biorepository, data hub, and core laboratories (genotyping, whole-exome sequencing, candidate gene evaluation, and variant confirmation). Eligibility includes all forms of CHD. Annual follow-up is obtained for probands <1-year-old. Parents are enrolled whenever available. Enrollment from December 2010 to June 2012 comprised 3772 probands. One or both parents were enrolled for 72% of probands. Proband median age is 5.5 years. The one third enrolled at age <1 year are contacted annually for follow-up information. The distribution of CHD favors more complex lesions. Approximately, 11% of probands have a genetic diagnosis. Adequate DNA is available from 97% and 91% of blood and saliva samples, respectively. Genomic analyses of probands with heterotaxy, atrial septal defects, conotruncal, and left ventricular outflow tract obstructive lesions are underway. The scientific community's use of Pediatric Cardiac Genomics Consortium resources is welcome.

Accessing and evaluating urologic health information: differences by race/ethnicity and gender.

Patients with urologic symptoms seek information from a variety of sources outside the traditional health care arena. There are differences between the genders and racial/ethnic groups related to sources consulted and confidence in those sources.

Relationship of demographic and health factors to cognition in older adults in the ACTIVE study.

OBJECTIVE: Examine the relationship of demographics and health conditions, alone and in combination, on objective measures of cognitive function in a large sample of community-dwelling older adults. METHOD: Baseline data from 2,782 participants in the Advanced Cognitive Training in Independent and Vital Elderly (ACTIVE) study were used to examine relationships of demographics and health conditions with composite scores of memory, reasoning, and speed of processing. RESULTS: Younger age, increased education, and White race were independently associated with better performance in each cognitive domain after adjusting for gender and health conditions. Male gender, diabetes, and suspected clinical depression were associated with poorer cognitive functioning; suspected clinical depression was associated with lower reasoning and diabetes and history of stroke with slower speed of processing. DISCUSSION: Age, education, and race are consistently associated with cognitive performance in this sample of older community-dwelling adults. Diabetes, stroke, and suspected clinical depression had independent but weaker effects on cognition.

Spiritual well-being in patients with advanced heart and lung disease.

OBJECTIVE: The purpose of this study was to evaluate levels of spiritual well-being over time in populations with advanced congestive heart failure (CHF) or chronic obstructive lung disease (COPD). METHOD: In a prospective, longitudinal study, patients with CHF or COPD (each n = 103) were interviewed at baseline and every 3 months for up to 30 months. At each interview, patients completed: the basic faith subscale of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) questionnaire, the Memorial Symptom Assessment Scale (MSAS), the Rand Mental Health Inventory (MHI), the Multidimensional Index of Life Quality (MILQ), the Sickness Impact Profile (SIP), and the Short Portable Mental Health Questionnaire (SPMSQ). RESULT: The mean age was 65 years, 59% were male, 78% were Caucasian, 50% were married, 29% lived alone, and there was no significant cognitive impairment. Baseline median FACIT-Sp score was 10.0 on a scale of 0-16. FACIT-Sp scores did not change over time and multivariate longitudinal analysis revealed higher scores for black patients and lower scores for those with more symptom distress on the MSAS-Global Distress Index (GDI) (both p = 0.02). On a separate multivariate longitudinal analysis, MILQ scores were positively associated with the FACIT-Sp and the MHI, and negatively associated with the MSAS-GDI and the SIP (all p-values < 0.001). SIGNIFICANCE OF RESULTS: In advanced CHF and COPD, spiritual well-being remains stable over time, it varies by race and symptom distress, and contributes to quality of life, in combination with symptom distress, mental health and physical functioning.

The ACTIVE cognitive training interventions and trajectories of performance among older adults.

OBJECTIVES: Salthouse illustrated that among Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) participants, cognitive change accelerated following training. Our goal was to determine if this finding persists net of practice, training, and loss of training gains effects. METHODS: We evaluated change over 5 years following cognitive training among older adults (N = 1,659, age 65 to 94). RESULTS: Reasoning training, but not memory or speed, attenuated aging-related change. Memory gains were maintained, but about half of reasoning and speed gains were lost. Performance differences at the end of the follow-up were equivalent to about 6, 4, and 8 years of aging for memory, reasoning, and speed training, respectively. DISCUSSION: Training can appear to accelerate age-related change, because change over time is coupled with loss of training gains. Our analysis is limited by follow-up that is short for precisely characterizing aging-related change.

Condition-specific quality of life 24 months after retropubic and transobturator sling surgery for stress urinary incontinence.

AIMS: To compare quality of life (QoL) and factors associated with QoL change after retropubic (RMUS) and transobturator midurethral slings (TMUS) using the Incontinence Impact Questionnaire (IIQ) and the International Consultation on Incontinence Questionnaire (ICIQ). METHODS: Five hundred ninety-seven women in a multicenter randomized trial of RMUS versus TMUS were examined. The IIQ and the ICIQ were obtained at baseline and at 12 and 24 months. Repeated-measures analysis of variance tested for differences by treatment group over time. Multivariable analysis identified factors associated with QoL change at 12 months postoperative, controlling for treatment group and baseline QoL. RESULTS: Improvement in IIQ was associated with the following: treatment success, younger age, improvement in stress urinary incontinence (SUI) symptom severity, and bother (all P < 0.05). Improvement in ICIQ was associated with treatment success, younger age, improvement in SUI symptom severity and bother, lower body mass index, and no reoperation (all P < 0.05). Improvement of the IIQ was stable over time (P = 0.35) for both treatment groups (P = 0.66), whereas the ICIQ showed a small but clinically insignificant decline (P = 0.03) in both treatment groups (P = 0.51). CONCLUSIONS: Postoperative QoL was improved after RMUS and TMUS. Measures of QoL functioned similarly, although more surgically modifiable urinary incontinence factors predicted improvement with the IIQ.

Complementary and alternative therapies for urinary symptoms: use in a diverse population sample qualitative study.

Study participants reported a range of remedies used to treat urinary symptoms, from popular products, such as saw palmetto, to less commonly known remedies, such as moabi. Participants learned about remedies through social network rather than from their primary care provider.

Talking with others about stigmatized health conditions: implications for managing symptoms.

We investigated the influence of social ties on symptom management and help seeking, using urinary symptoms as a case study. Talking with others about these symptoms was common and both facilitated and hindered symptom management and help seeking. In some cases, talking with others resulted in gaining a sense of identification with others suffering the same symptoms, receiving assistance to ease the burden of symptoms, obtaining suggestions to help manage symptoms, and learning information about available treatments. In other cases, talking with others served to normalize symptoms to such an extent that individuals saw no need to manage their symptoms differently.

Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey.

AIMS: To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB). METHODS: Five thousand five hundred three community-dwelling persons aged 30-79 were interviewed regarding urologic symptoms (2002-2005). NOAB was defined as symptoms of urgency and/or urgency incontinence among those with a self-reported history of healthcare provider diagnosed stroke (N = 98), multiple sclerosis (N = 21), or Parkinson's disease (N = 7). N-NOAB was defined identically but occurring among those not reporting neurologic disease (ND). Prevalence estimates were weighted to reflect sampling design; chi-square, Fisher's exact, or t-tests were used to test differences. Urologic symptom interference was assessed using the Epstein scale, while the impact of urinary incontinence (UI) on health-related quality-of-life (HRQOL) was measured using a modification of the Incontinence Impact Questionnaire-7. RESULTS: Forty-five (31.0%) of 125 persons with ND and 994 (16.7%) of 5378 persons without ND reported OAB symptoms. The overall prevalence of NOAB and N-NOAB was 0.6% and 16.4%, respectively. Persons with NOAB had higher (worse) mean American Urologic Association Symptom Index scores (13.0 vs. 10.0, P = 0.09) compared to those with N-NOAB, and were significantly more likely to have diabetes, high blood pressure, cardiac disease, and fair/poor self-reported health (all P < 0.05). Mean symptom interference and UI HRQOL scores were significantly higher (worse) in the NOAB group compared to persons with N-NOAB (all P < 0.05). CONCLUSIONS: Persons with NOAB appeared to have a greater burden of urologic illness with respect to symptom interference and HRQOL compared to persons with N-NOAB.

A qualitative inquiry of patient-reported outcomes: the case of lower urinary tract symptoms.

BACKGROUND: Patient-reported outcomes are a valuable tool for assessing healthcare, particularly for symptom-based conditions that lack definitive physiological measures of treatment efficacy. OBJECTIVE: To explore the value of qualitative methods for understanding and developing patient-reported outcomes of medical care for symptom-based conditions by examining the case of lower urinary tract symptoms. METHODS: Semistructured interviews were conducted with a diverse community sample of 90 respondents who had spoken with a provider about their urinary symptoms. Content and thematic analyses were conducted for the areas of symptom relief, patient adherence, and satisfaction with care according to gender, race or ethnicity, and socioeconomic status. RESULTS: Across social groups, most patients experienced either no symptom relief or partial relief, reported that they adhered to recommendations, and were satisfied with the care received. The primary reason for no symptom relief was not receiving a treatment recommendation. For patients, even partial relief made symptoms more manageable both physically and emotionally. Satisfaction with care was mediated by the quality of the patient-provider relationship as well as expectations other than symptom relief, particularly for patients of low socioeconomic status. DISCUSSION: Patients' assessments of the outcomes of seeking medical care for this symptom-based condition broadened the criteria for quality of care beyond providing a cure. For healthcare providers, this can widen the path for meeting patient needs, even without complete symptom relief. For providers and researchers, as the evidence base expands to include patient reports, the context provided by a qualitative approach can enhance understanding of patients' perspectives and the ability to construct meaningful quantitative measures.

Associations of commonly used medications with urinary incontinence in a community based sample.

PURPOSE: We examined the association between the use of medications and the prevalence of urinary incontinence in gender specific analyses of a community based, representative sample. MATERIALS AND METHODS: A population based epidemiological study was conducted of 5,503 men and women 30 to 79 years old residing in Boston, Massachusetts (baseline data collected from 2002 to 2005). Urological symptoms were ascertained in a 2-hour, in person interview. Urinary incontinence was defined as urine leakage occurring weekly or more often during the last year. Medications used in the last month were considered current use. Associations of 20+ medications and prevalent urinary incontinence were examined using multivariate logistic regression (ORs and 95% CIs) with adjustments for known urinary incontinence risk factors. RESULTS: The prevalence of urinary incontinence in the analysis sample was 9.0% in women and 4.6% in men. For women the prevalence was highest among users of certain antihistamines (28.4%) and angiotensin II receptor blockers (22.9%). For men the prevalence was highest among angiotensin II receptor blocker (22.2%) and loop diuretic (19.1%) users. After final multivariate adjustment there were significant positive associations for certain antihistamines, beta receptor agonists, angiotensin II receptor blockers and estrogens with urinary incontinence in women (all ORs greater than 1.7), and a borderline significant association for anticonvulsants (OR 1.75; 95% CI 1.00, 3.07). Among men only anticonvulsants were associated with urinary incontinence after final adjustments (OR 2.50; 95% CI 1.24, 5.03), although angiotensin II receptor blockers showed an adjusted association of borderline significance (OR 2.21; 95% CI 0.96, 5.10). CONCLUSIONS: Although a cross-sectional analysis cannot determine causality, our analysis suggests certain medications should be further examined in longitudinal analyses of risk to determine their influence on urological symptoms.

A randomized trial of urodynamic testing before stress-incontinence surgery.

BACKGROUND: Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes. METHODS: We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of "much better" or "very much better" on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points. RESULTS: A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, -0.3 percentage points; 95% confidence interval, -7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes. CONCLUSIONS: For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.).

ACTIVE cognitive training and rates of incident dementia.

Systematic cognitive training produces long-term improvement in cognitive function and less difficulty in performing activities of daily living. We examined whether cognitive training was associated with reduced rate of incident dementia. Participants were from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (n = 2,802). Incident dementia was defined using a combination of interview- and performance-based methods. Survival analysis was used to determine if ACTIVE treatment affected the rate of incident dementia during 5 years of follow-up. A total of 189 participants met criteria for incident dementia. Baseline factors predictive of incident dementia were older age, male gender, African American race, fewer years of education, relationship other than married, no alcohol use, worse MMSE, worse SF-36 physical functioning, higher depressive symptomatology, diabetes, and stroke (all p < .05). A multivariable model with significant predictors of incident dementia and training group revealed that cognitive training was not associated with a lower rate of incident dementia. Cognitive training did not affect rates of incident dementia after 5 years of follow-up. Longer follow-up or enhanced training may be needed to fully explore the preventive capacity of cognitive training in forestalling onset of dementia.

Patients' experiences of seeking health care for lower urinary tract symptoms.

A gap between experiencing symptoms and receiving effective treatment persists for people with lower urinary tract symptoms (LUTS), even for those who seek health care. In order to better understand how patients experience treatment seeking for LUTS, we interviewed a racially diverse sample of 90 men and women with a range of LUTS about their experiences seeking care. Thematic analysis revealed that patients often disclosed urinary symptoms first to primary care providers during a general examination or a visit for another health problem. Patients seek provider assistance typically when symptoms have intensified or are causing worry, and a desire for treatment trumps potential embarrassment; among women patients, feeling comfortable with a provider also is important for disclosing LUTS.