Intestinal Inflammation is Significantly Associated With Length Faltering in Preterm Infants at Neonatal Intensive Care Unit Discharge.

OBJECTIVE: The aim of the study was to assess intestinal inflammatory measures, urinary intestinal fatty acid-binding protein (IFABP), and fecal calprotectin (FC) by gestational age (GA) and postmenstrual age (PMA) and determine the association between intestinal inflammation and growth in preterm infants from birth to hospital discharge. We hypothesized that intestinal inflammation is associated with adverse growth in preterm infants. METHODS: We assayed repeated measures of IFABP and FC in 72 hospitalized preterm infants (<34 weeks' gestation). We calculated weight and length z scores at birth and discharge using the Fenton growth reference. Associations between mean IFABP or FC, growth z scores at discharge, and growth faltering (weight or length z score difference <-0.8 from birth to discharge) were assessed using mixed linear and logistic regression models, adjusted for intrafamilial correlation and potential confounders: GA, sex, birth z score, race/ethnicity, and maternal age. RESULTS: Mean IFABP was greater among infants born at earlier GA and decreased with increasing PMA. Mean FC did not vary by GA or PMA. Higher mean IFABP and FC were associated with lower discharge growth z scores and greater likelihood of growth faltering significant only for mean IFABP and discharge length z score (ß = -0.353, 95% confidence interval [CI]: -0.704 to -0.002) and mean IFABP and length faltering (odds ratio [OR] 1.99, P = 0.018). CONCLUSIONS: Intestinal inflammation, measured by IFABP, was associated with lower length z scores and length faltering at discharge. Interventions to prevent intestinal inflammation may improve linear growth among preterm infants.

A contemporary lower pole approach for complete staghorn calculi: outcomes and efficacy.

PURPOSE: Percutaneous nephrolithotomy (PCNL) is the preferred surgical treatment for staghorn stones. Two approaches are commonly employed to gain access into the collecting system which consists of either an upper pole (UP) approach or lower pole (LP) approach. However, opinions vary on which approach offers the best access and outcome. In this study, we aim to challenge the traditional paradigm that staghorn stones are most effectively treated through a prone UP approach. We herein report our institutional experience using a prone LP access in PCNL for patients with complete staghorn stones. METHODS: Data were prospectively collected over 3 years on 473 PCNL procedures, of which 76 patients had complete staghorn calculi (five or more calyces). Operative and peri-operative outcomes were analyzed to compare a modified LP approach with the more widely accepted UP approach. RESULTS: A total of 59/76 (77.6%) patients had LP access. There was no difference in the ability of completing the surgery utilizing a single tract as opposed to multiple tracts (74.6% of LP patients vs. 76.5% of UP patients). Stone-free rates for LP and UP access were similar (74.5 versus 70.5%, respectively; p = 0.760. Complication rates were lower for LP access vs. UP access (3.4 vs. 23.5%, p = 0.02) with two pulmonary complications in the UP group. Overall median operative time was not significantly different between LP and UP access (112.0 vs. 126.0 min, p = 0.486). CONCLUSIONS: Prone LP access demonstrated similar efficacy with decreased morbidity in patients with complete staghorn calculi compared to prone UP access.

Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes.

PURPOSE: We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones. MATERIALS AND METHODS: We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test. RESULTS: Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m2, p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement. CONCLUSIONS: Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum.

Long-term dysbiosis and fluctuations of gut microbiome in antibiotic treated preterm infants.

Postnatal acquisition of the microbiome is critical to infant health. In preterm infants, empiric use of antibiotics is common, with significant health consequences. To understand the influence of antibiotics on acquisition of the microbiome over time, we longitudinally profiled microbial 16S rRNA in the stool of 79 preterm infants during their hospitalization in the intensive care unit and compared antibiotic treated and untreated infants. Despite similar clinical presentation, antibiotic treated infants had strong deviations in the content, diversity, and most dramatically, temporal stability of their microbiome. Dysbiosis and fluctuations of microbiome content persisted long after antibiotic exposure, up to hospital discharge. Microbiome diversity was dominated by a few common bacteria consistent among all infants. Our findings may inform clinical practice related to antibiotic use and targeted microbial interventions aimed at overcoming the adverse influence of antibiotics on the microbiome of preterm infants at specific developmental time points.

Clinical overlap between Jakob-Creutzfeldt disease and Lewy body disease.

OBJECTIVE: Sporadic Jakob-Creutzfeldt disease (sCJD) and dementia with Lewy bodies (DLB) have overlapping clinical symptoms that can lead to their misdiagnosis. We delineated the clinical overlap between sCJD and DLB, and assessed the value of magnetic resonance imaging (MRI) to differentiate between them. METHODS: Medical records, MRI, electroencephalogram (EEG) and cerebrospinal fluid (CSF) were reviewed from 56 sCJD and 30 DLB subjects. RESULTS: 46% of sCJD subjects met probable DLB criteria and 40% of DLB subjects met probable CJD criteria. A greater proportion of sCJD subjects had cerebellar signs (66% vs. 10%, p<0.001), myoclonus (64% vs. 30%, p=0.002), and visual symptoms (other than hallucinations) (61% vs. 7%, p<0.001), whereas more DLB subjects had hallucinations (70% vs. 39%, p=0.007) and fluctuations (57% vs. 23%, p=0.002). Cortical and/or basal ganglia MRI diffusion weighted imaging hyperintensities consistent with sCJD were seen in 96% of sCJD subjects but in none with DLB. Logistic regression in sCJD revealed that those meeting probable DLB criteria were more likely to have occipital lobe involvement on MRI (OR 1.4, p=0.058, model p=0.022). Parietal lobe involvement on MRI was a predictor of "Other Focal Cortical signs" (OR 1.9, p=0.021). EEG and CSF assessments lacked sensitivity for sCJD as 48% of sCJD patients had a negative EEG; 67% of the 36 sCJD patents with a CSF evaluation had a negative or inconclusive 14-3-3 result. Too few DLB patients had EEG or CSF to assess their utility. CONCLUSION: Sporadic CJD and DLB have significant symptom overlap. MRI helps differentiate these diseases and is related to the signs/symptoms observed in sCJD.

A quality improvement initiative to reduce acid-suppressing medication exposure in the NICU.

BACKGROUND: Acid-suppressing medications (ASMs) are commonly prescribed in the neonatal intensive care unit (NICU), in particular among preterm infants, despite well-established adverse effects and little evidence to support efficacy. LOCAL PROBLEM: We sought to develop an initiative to reduce ASM exposure in our predominantly inborn level III NICU. Our specific aim was to reduce the number of nonindicated ASM prescriptions by 50% within a 12-month period. METHODS: Our multidisciplinary team developed an evidence-based guideline defining indications for ASM prescription in a level III NICU. Plan-do-study-act cycles included staff education, formal clinical practice guideline implementation, and implementation of standardized documentation tools in the electronic health record (EHR). Outcome measures were the number of nonindicated and total inpatient prescriptions started per month, duration of ASM prescription, and number of prescriptions continued after NICU discharge. Balancing measures were the number of patients started on thickened feeds and number of patients discharged home on nasogastric tube feeds. We used statistical process control and Pareto charts to assess these measures over a 12-month baseline period, 9-month implementation period, and 19-month post-implementation period spanning September 2017-December 2020. RESULTS: Nonindicated ASM prescriptions decreased from median 3 to 0 per month from the baseline to post-implementation period. Simultaneously, the median number of ASM prescriptions at discharge declined from 2 to 0 per month. The median duration of inpatient prescriptions declined from 23 to 7 days. Rates of patients started on thickened feeds and patients discharged home on nasogastric tube feeds remained stable throughout the study. CONCLUSION: Enactment of an evidence-based guideline was associated with a substantial decline in nonindicated ASM use in our NICU and a decline in duration of exposure to ASM's when prescribed. Our interventions proved effective in altering clinical practice and could be applied to other NICUs with similar patient populations aiming to reduce ASM use.

Perceptions and Experiences of Family Physicians Regarding Firearm Safety Counseling.

BACKGROUND AND OBJECTIVES: Despite the growing rate of deaths caused by firearms, it is not clear what role physicians should play in counseling patients about firearm safety. This study aims to delineate the perceptions and experiences of family physicians regarding firearm safety counseling. METHODS: Data were gathered as part of the 2020 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of family medicine practicing physicians. Participants were practicing physicians and members of one of four major academic family medicine organizations comprising CERA. The survey was delivered to a sample of 3,665 family physicians between January 15, 2020, and March 2, 2020. This was a mixed-methods epidemiological study that analyzed quantitative and qualitative survey data. We calculated a χ2 test of independence to examine interactions between demographic characteristics and beliefs and perceptions about firearm safety counseling. RESULTS: The overall response rate for the survey was 32.52%, with 92.7% answering questions in the firearm safety set; 93.7% of study participants viewed firearm safety as a public health issue and 95.3% felt family physicians should have the right to counsel patients on firearm safety. Family physicians who had received formal training on firearm safety counseling were significantly more likely to indicate a higher level of comfort with asking their patients about firearms (P<.0001). CONCLUSIONS: Firearm safety is an important public health issue and family physicians would benefit from receiving formal training on firearm safety counseling early in their training. More education is needed around physician-initiated firearm safety counseling.

Elevated Intestinal Inflammation in Preterm Infants With Signs and Symptoms of Gastroesophageal Reflux Disease.

OBJECTIVES: Reflux is common in infancy; however, persistent signs and symptoms of gastrointestinal distress are often attributed to gastroesophageal reflux disease (GERD). In this pilot study, we aimed to characterize associations between signs and symptoms of suspected GERD and noninvasive markers of intestinal inflammation in preterm infants. METHODS: We reviewed Electronic Medical Record (EMR) data to identify clinical signs and symptoms among case patients (n = 16). Controls (n = 16) were matched on gestational age. Univariate and multivariate regression analyses were used to compare fecal calprotectin and urinary intestinal fatty acid binding protein (I-FABP) levels between cases and controls. RESULTS: We found no differences in baseline characteristics between cases and controls. In the multivariate regression analysis controlling for the proportion of mother's milk, cases had higher fecal calprotectin levels than controls, with no differences in I-FABP levels between cases and controls. CONCLUSION: Our findings suggest that preterm infants with signs and symptoms of GERD have higher levels of intestinal inflammation as indicated by fecal calprotectin compared to their controls. Further studies are needed to evaluate the role of intestinal inflammation in signs and symptoms of gastrointestinal distress and whether fecal calprotectin might have predictive value in diagnosing GERD.

Bioactive Factors in Human Breast Milk Attenuate Intestinal Inflammation during Early Life.

Human breast milk is well known as the ideal source of nutrition during early life, ensuring optimal growth during infancy and early childhood. Breast milk is also the source of many unique and dynamic bioactive components that play a key role in the development of the immune system. These bioactive components include essential microbes, human milk oligosaccharides (HMOs), immunoglobulins, lactoferrin and dietary polyunsaturated fatty acids. These factors all interact with intestinal commensal bacteria and/or immune cells, playing a critical role in establishment of the intestinal microbiome and ultimately influencing intestinal inflammation and gut health during early life. Exposure to breast milk has been associated with a decreased incidence and severity of necrotizing enterocolitis (NEC), a devastating disease characterized by overwhelming intestinal inflammation and high morbidity among preterm infants. For this reason, breast milk is considered a protective factor against NEC and aberrant intestinal inflammation common in preterm infants. In this review, we will describe the key microbial, immunological, and metabolic components of breast milk that have been shown to play a role in the mechanisms of intestinal inflammation and/or NEC prevention.

The influence of spouse lower cognitive function on partner health and well-being among community-dwelling older couples: moderating roles of gender and marital problems.

OBJECTIVES: To analyze longitudinal relationships between older spouses' lower cognitive function and the health and well-being of their partners five years later and to assess the moderating roles of gender and marital problems. METHODS: Subjects were 404 community-dwelling older couples from the Alameda County Study. Baseline cognitive function was measured with a scale assessing problems remembering names, finding the right word, misplacing things and paying attention. Follow-up measures included five health and well-being outcomes. Statistical models adjusted for paired data and included spouse and partner cognitive function as well as partner baseline values for each outcome. Interaction terms assessed gender differences; stratified models assessed the moderating roles of marital problems. RESULTS: Husbands' lower cognitive function was associated with subsequent poorer health and well-being for their wives; however, these associations were significant only for the 52% reporting few or no marital problems. Wives' lower cognitive function was not associated with any outcomes for their husbands. CONCLUSION: Our findings support early identification of cognitive decline and development of assistive strategies for wives dealing with relationship changes associated with lower cognitive function in their husbands. Although our finding that associations were limited to wives in marriages with few or no problems is consistent with a communication framework, further research is necessary to better understand this strong gender difference.

A Randomized, Double-Blind, Sham-Controlled Study Assessing Electroacupuncture for the Management of Postoperative Pain after Percutaneous Nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for large renal calculi but postoperative (PO) pain remains a concern. Modifications of the PCNL technique and intraoperative and PO strategies have been tested to reduce pain. PO pain control reducing risk of long-term pain medication and narcotic use is of considerable importance. Acupuncture is a common medical procedure shown to alleviate PO pain. Some benefits are that it is nonpharmacologic, easy to administer, and safe. The purpose of this study was to evaluate the effects of electroacupuncture (EA) on PO pain in patients undergoing PCNL. MATERIALS AND METHODS: This was a randomized, double-blind, sham-controlled study. The study was Institutional Review Board approved and performed under standard ethical guidelines. Fifty-one patients undergoing PCNL by a single surgeon were randomized to one of the three groups: true EA (n = 17), sham EA (SEA, n = 17), and no acupuncture (control, n = 17). The EA and SEA were performed by a single licensed acupuncturist <1 hour before operation. PCNL was performed without the use of intraoperative nerve block(s) or local anesthetic. Pain scores (visual analog scale [VAS]), narcotic use (morphine equivalents), and side effects were recorded at set intervals postoperatively. RESULTS: Mean VAS scores for flank and abdomen pain were lower at all time periods in the EA compared with the SEA and control groups. Mean cumulative opioid usage was lower in the EA group immediately postoperatively compared with both SEA and control groups. Two patients in the EA group did not require any PO narcotics. No differences between groups were found for PO nausea and vomiting. No adverse effects of EA or SEA were noted. CONCLUSIONS: EA significantly reduced PO pain and narcotic usage without any adverse effects after PCNL. This promising treatment for managing PO pain warrants further investigation.

Predicting the Impacted Ureteral Stone with Computed Tomography.

OBJECTIVE: To evaluate whether preoperative computed tomography (CT) findings could predict the presence of an impacted stone. Preoperative identification of an impacted ureteral stone may influence patient preparation and operative decisions. Factors predicting ureteral stone impaction have not been clearly identified. METHODS: We identified all patients from June 2014 to July 2016 that underwent ureteroscopic treatment of an impacted ureteral stone. Patients that had ureteral prestenting or previous treatment for their stone were excluded. Noncontrast CT images were reviewed to calculate stone size, stone volume, degree of hydronephrosis (0-3), and Hounsfield units (HU) of the stone as well as the ureter distal and proximal to the stone. These were compared with a control group of patients that had nonimpacted stones. RESULTS: Patients with impacted stones had a greater stone size, volume, HU of the ureter under the stone, HU under/above ratio, and degree of hydronephrosis on univariate analysis. Multivariate analysis demonstrated that HU under the stone was a significant predictor of ureteral stone impaction (odds ratio 1.17; 95% confidence interval 1.11-1.25). Distal ureteral density above 27 HU demonstrated a sensitivity of 85%, specificity of 85%, positive predictive value of 89%, and negative predictive value of 81% for ureteral stone impaction. CONCLUSION: Impacted stones are associated with ureteral density cut-off value of 27 HU or greater. Measuring this value on preoperative noncontrast CT may help predict which patients are more likely to have impacted stones.

Recurrent Kidney Stone Episodes Leading to a Diagnosis of Occult Acromegaly.

The association between nephrolithiasis and acromegaly has been previously described. Although the mechanism has been established, the urological literature sparsely discusses clinically suspecting that patients with recurrent nephrolithiasis could have acromegaly and subsequently referring them for accurate diagnosis and treatment. We present a case of occult acromegaly secondary to a pituitary tumor discovered 20 years after the patient's first stone episode.

A Multi-Institutional Study of Struvite Stones: Patterns of Infection and Colonization.

OBJECTIVE: To examine urine and stone bacteriology of struvite stone formers in a large cohort of patients undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A total of 1191 patients, with stone and urine cultures, treated with PCNL for renal calculi were included in the study. Statistical differences were assessed using Mann-Whitney U and T-tests. RESULTS: Stone cultures were positive in 72% of patients with struvite stones. Urea-splitting organisms accounted for only half of the positive stone cultures. Enterococcus (9/50, 18%), Proteus (9/50, 18%), and Escherichia coli (6/50, 12%) were the most commonly identified organisms. Notably, two-thirds of struvite formers with negative stone culture had at least one positive culture for a urea-splitting organism on urine culture going back 1 year from the time of surgery. A majority (67%) of struvite stone cultures were found to be resistant to first- and second-generation cephalosporins. CONCLUSIONS: The bacteriology of struvite stones has shifted away from traditional urea-splitting organisms and antibiotic coverage must be expanded to include organisms such as Enterococcus that do not respond to cephalosporins. Causative organisms may be found by going back in time to identify the initial organism that could have induced struvite stone formation to inform preventative therapy.

"If You Don't Know, All of a Sudden, They're Gone": Caregiver Perspectives About Prognostic Communication for Disabled Elderly Adults.

OBJECTIVES: To describe preferences and experiences of caregivers of disabled older adults regarding being included in patient-clinician discussions about life expectancy. DESIGN: Qualitative interview study. SETTING: Caregivers were recruited from a Program of All-Inclusive Care for the Elderly (PACE), caregiver support groups and an advertisement on a nationwide caregiver advocacy group website. PARTICIPANTS: Active and bereaved caregivers whose primary language was either English or Cantonese who had provided care within the last 5 years to a disabled adult aged 65 and older (N = 42, 79% female, 60% white, average age 54). MEASUREMENTS: Semistructured telephone interviews were conducted with caregivers who were asked about experiences and preferences related to clinician communication about life expectancy, including preferences for and attitudes toward being included in discussions about life expectancy, how such information should be delivered, and how clinicians should address concerns about uncertainty and hope. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached. RESULTS: Twenty-six percent of caregivers had been involved in a conversation with a clinician about life expectancy, even though 79% expressed a preference to have such a discussion. According to caregivers, clinician concerns about taking away hope or the uncertainty of prognostic information should not deter them from bringing up the topic of life expectancy. Thematic analysis suggested several approaches that may facilitate prognosis communication: establishing a relationship with the caregiver and care recipient; delivering the prognosis in clear, plain language; and responding to emotion with empathy. CONCLUSION: Caregivers reported a preference for being included in conversations about a care recipient's life expectancy.

"It Just Consumes Your Life": Quality of Life for Informal Caregivers of Diverse Older Adults With Late-Life Disability.

Little is known about the quality of life (QoL) for informal caregivers of disabled older adults aged 65+ with diverse backgrounds. Forty-two caregivers were interviewed in English and Cantonese about their caregiving experiences, their recollections of QoL over time, and the factors influencing their appraisals. Overall, 52% of caregivers experienced a decline in QoL. Factors associated with decreased QoL were less time for self, competing financial demands, and the physical and emotional impact of the patient's illness. Factors associated with no change in QoL were minimal caregiving responsibilities, a sense of filial duty, and QoL being consistently poor over time. Factors associated with improved QoL were perceived rewards in caregiving, receiving institutional help, and increased experience. Chinese caregivers were more likely to cite filial duty as their motivator for continued caregiving than were Caucasian caregivers. In conclusion, informal caregivers take on a huge burden in enabling older adults to age in the community. These caregivers need more support in maintaining their QoL.

Comparing CSF biomarkers and brain MRI in the diagnosis of sporadic Creutzfeldt-Jakob disease.

We assessed the diagnostic utility of 3 CSF biomarkers-14-3-3 protein, total tau (T-tau), and neuron-specific enolase (NSE)-from the same lumbar puncture to distinguish between participants with neuropathologically confirmed sporadic Creutzfeldt-Jakob disease (sCJD, n = 57) and controls with nonprion rapidly progressive dementia (npRPD, n = 41). Measures of diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value, as well as logistic regression and area under the receiver operator curve (AUC), were used to assess the ability of these CSF biomarkers, alone or concomitantly, to predict diagnosis. In a subcohort with available MRI (sCJD n = 57, npRPD = 32), we compared visual assessment of diffusion-weighted imaging MRI sequences to these CSF biomarkers. MRI was the best predictor, with an AUC of 0.97 (confidence interval [CI] 0.92-1.00) and a diagnostic accuracy of 97% (CI 90%-100%). Of the CSF biomarkers, T-tau had a higher diagnostic accuracy (79.6%) than 14-3-3 (70.4%, CI for difference 8.7%, 9.7%; p = 0.048) or NSE (71.4%, CI for difference 7.6%, 8.7%; p = 0.03).

Every patient is an individual: clinicians balance individual factors when discussing prognosis with diverse frail elderly adults.

BACKGROUND: To explore clinician choice of whether to discuss prognosis with their frail older patients. DESIGN: Qualitative interview study. SETTING: Primary care clinicians were recruited from nursing homes, community-based clinics, and academic medical centers. PARTICIPANTS: Three geriatric nurse practitioners, nine geriatricians, five general internists, and three family medicine physicians with a mean age of 44 and a mean 12 years in practice. Seventeen clinicians had patient panels with 80% or more community-dwelling outpatients, 13 had patient panels with 50% or more patients aged 85 and older, and 16 had patient panels with 25% or more of patients in a minority group (Asian, African American, Hispanic). MEASUREMENTS: Clinicians were asked to describe their practice of discussing long-term (<5-year) and short-term (<1-year and 3-month) prognosis. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached. RESULTS: Clinicians reported individualizing the decision to discuss prognosis with their frail older patients based on clinical circumstances. Common reasons for discussing prognosis included patient had a specific condition with a limited prognosis, to give patients time to prepare, to promote informed medical decision-making, and when patients or families prompted the conversation. Common reasons not to discuss included maintaining hope and avoiding anxiety, cognitive impairment or patient unable to understand prognosis, respect for patients' cultural values, and long-term prognosis too uncertain to be useful. CONCLUSION: Clinicians caring for frail older adults are generally willing to discuss short- but not long-term prognosis. Clinicians balance individual factors when deciding whether to discuss prognosis.

Glycemic control and urinary incontinence in women with diabetes mellitus.

BACKGROUND: Although many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c) level and urinary incontinence in a large, diverse cohort of older women. METHODS: We examined 6026 older women who responded to a survey (62% response rate) and were enrolled in the Diabetes and Aging Study, an ethnically stratified random sample of patients with diabetes enrolled in Kaiser Permanente Northern California. Our primary independent variable was the mean of all HbA1c measurements in the year preceding the survey. Outcomes included the presence/absence of incontinence and limitations in daily activities due to incontinence. We used modified Poisson regression and ordinal logistic regression models to account for age, race, body mass index, parity, diabetes treatment, duration of diabetes, and comorbidity. RESULTS: Sixty-five percent of women reported incontinence (mean age 59±10 years). After adjustment, HbA1c levels were not associated with the presence or absence of incontinence. However, among women reporting incontinence, HbA1c ≥9% was associated with more limitations due to incontinence than HbA1c <6% (adjusted odds ratio 1.67, 95% confidence interval: 1.09-2.57). CONCLUSION: In this cross-sectional analysis, HbA1c level is not associated with the presence or absence of incontinence. However, for women with incontinence, poor glycemic control (HbA1c ≥9%) is associated with more limitations in daily activities due to incontinence. Longitudinal studies are needed to determine whether improving glycemic control to HbA1c <9% leads to fewer limitations in daily activities due to incontinence.