Effects of pulmonary rehabilitation on cardiac magnetic resonance parameters in patients with persistent dyspnea following pulmonary embolism.

Background: Persistent dyspnea and reduced exercise capacity is common in pulmonary embolism (PE) survivors. Although improved right ventricular function after pulmonary rehabilitation has been demonstrated in chronic thromboembolic pulmonary hypertension, it is still unknown whether a similar effect also occurs in other patients with dyspnea after pulmonary embolism. Purpose: The aim of this study was to explore potential effects of a pulmonary rehabilitation program on cardiac structure and function as assessed with cardiac magnetic resonance (CMR). Material and methods: Twenty-six PE survivors with persistent dyspnea were included. Right and left ventricular assessment with CMR was performed before and after an eight-week pulmonary rehabilitation program. Results: Dyspnea as measured by the Shortness of Breath Questionnaire improved significantly after rehabilitation: 15 (IQR: 7-31) versus 8 (IQR: 3-17). Absolute right ventricular global longitudinal strain by CMR was reduced from 19% to 18% (95% CI of difference: 0-3 percent points), and absolute RV lateral strain from 26% to 24% (95% CI of difference: 1-4 percent points). Right ventricular mass was reduced after rehabilitation from 49 g to 44 g (95% CI of difference: 2-8 g). Conclusion: Although there was a substantial improvement in dyspnea after rehabilitation, we found only a minor reduction in absolute right ventricular longitudinal strain and right ventricular mass. No other CMR parameter changed. We therefore suggest that rehabilitation effect of in this patient group was not primarily mediated by cardiac adaptions.

Vitamin D and stress urinary incontinence in pregnancy: a cross-sectional study.

OBJECTIVE: To assess the association between levels of vitamin D and urinary incontinence (UI) in pregnancy. DESIGN: A cross-sectional study. Secondary analysis of a randomised controlled trial. SETTING: Two university hospitals in Norway. POPULATION: A total of 851 healthy, pregnant women >18 years in gestational weeks 18-22 with a singleton live fetus. METHODS: Data on UI were collected from a questionnaire at inclusion and serum analysis of 25-hydroxy vitamin D (25(OH)D) was performed. Univariable and multivariable logistic regression analyses were applied to study associations between exposure and outcomes. MAIN OUTCOME MEASURES: Prevalence of self-reported UI, stress (SUI) and urge (UUI) or mixed UI. RESULTS: In total, 230/851 (27%) of the participants were vitamin D insufficient (25(OH)D <50 nmol/l) and 42% reported to have any UI. Women with 25(OH)D <50 nmol/l were more likely to report any UI (P = 0.03) and SUI (P < 0.01) compared with women with 25(OH)D ≥50 nmol/l. In a univariable logistic regression analysis, serum levels of 25(OH)D <50 nmol/l was associated with increased risk of any UI (odds ratio [OR] 1.5 with 95% CI 1.0-2.1), SUI only (OR 1.7, 95% CI 1.2-2.4), but not mixed UI or UUI only (OR 0.8, 95% CI 0.5-1.5). In a multivariable logistic regression model, serum levels of 25(OH)D <50 nmol/l were associated with a higher risk of experiencing SUI only (OR 1.5, 95% CI 1.1-2.2). CONCLUSIONS: Serum 25(OH)D <50 nmol/l was associated with increased risk of any UI, and SUI in particular. TWEETABLE ABSTRACT: Low levels of vitamin D are associated with increased risk of urinary incontinence in pregnancy.

Evolution and risk factors of anal incontinence during the first 6 years after first delivery: a prospective cohort study.

OBJECTIVE: To explore changes in prevalence of anal incontinence (AI) from late first pregnancy to 6 years postpartum, and to evaluate possible risk factors for changes in AI during the 6-year period. DESIGN: Prospective longitudinal cohort study. SETTING: Two Norwegian health regions. POPULATION OR SAMPLE: Women with first deliveries between May 2009 and December 2010. METHODS: Participants reported AI in late pregnancy, 6 months, 1 and 6 years after first delivery using postal or digital questionnaires. AI prevalence was calculated, and mixed effects Poisson regression analyses with robust variance were applied. MAIN OUTCOME MEASURES: AI from late pregnancy to 6 years postpartum. RESULTS: Among 1571 participants, 65% had normal vaginal first deliveries, 20% had vaginal deliveries complicated by instrumental intervention and/or obstetric anal sphincter injury (IVD ± OASIS). Nearly 1 in 10 women reported persistent incontinence during the 6 years. The overall AI prevalence was reduced from late pregnancy to 1 year postpartum for all modes of delivery. At 6 years postpartum, women with IVD ± OASIS had a higher AI prevalence (23%; 95% CI 16-30%) compared with women with caesarean section (8%; 95% CI 2-13%) or normal vaginal delivery (12%; 95% CI 9-16%). Moreover, women who were <23 years, ≥34 years, unemployed during first pregnancy, who had active bowel disease (PR: 2.4; 95% CI 2.0-2.7), or bowel evacuation problems during the 6-year period had higher AI prevalence. CONCLUSIONS: Mode of first delivery modified AI prevalence during the 6-year period, whereas age, bowel disease and bowel evacuation problems were associated with higher prevalence of AI from late first pregnancy to 6 years postpartum. TWEETABLE ABSTRACT: Complicated vaginal delivery, age and bowel emptying problems increase the risk of long-term anal incontinence.

Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial.

OBJECTIVE: To evaluate the effect of pelvic floor muscle exercises (PFME) for postpartum anal incontinence (AI). DESIGN: A parallel two-armed randomised controlled trial stratified on obstetrical anal sphincter injury with primary sphincter repair and hospital affinity. SETTING: Ano-rectal specialist out-patient clinics at two hospitals in Norway. POPULATION: One hundred and nine postpartum women with AI at baseline. METHODS: The intervention group received 6 months of individual physiotherapy-led PFME and the control group written information on PFME. Changes in St. Mark's scores and predictors of post-intervention AI were assessed by independent samples t-tests and multiple linear regression analyses, respectively. The study was not blind. MAIN OUTCOME MEASURES: The primary outcome measure was change in AI symptoms on the St. Mark's score from baseline to post-intervention. Secondary outcome measures were manometry measures of anal sphincter length and strength, endoanal ultrasound (EAUS) defect score and voluntary pelvic floor muscle contraction. RESULTS: There was a significant difference in the reduction of St. Mark's scores from baseline to post-intervention in favour of the PFME group (-2.1 versus -0.8 points, P = 0.040). No differences in secondary outcome measures were found between groups. Baseline St. Mark's, PFME group affinity and EAUS defect score predicted post-intervention St. Mark's score in the imputed intention-to-treat analyses. The analysis on un-imputed data showed that women performing weekly PFME improved their AI scores more than women in the control group did. CONCLUSIONS: Our results indicate that individually adapted PFME reduces postpartum AI symptoms. TWEETABLE ABSTRACT: Performing regular pelvic floor muscle exercises may be an effective treatment for postpartum anal incontinence.

Anal incontinence and Quality of Life in late pregnancy: a cross-sectional study.

OBJECTIVE: To evaluate the association between different types of anal incontinence (AI) and Quality of Life (QoL) in late pregnancy. DESIGN: Cross-sectional study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 or over. METHODS: Participants answered questions about AI during the last 4 weeks of pregnancy on the St. Mark's score and impact of QoL in the Fecal Incontinence QoL score. Socioeconomic data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI and impact on QoL. RESULTS: 1571 primiparae responded; 573 (37%) had experienced AI during the last 4 weeks of pregnancy. One third of the incontinent women reported reduced QoL in the domain 'Coping'. 'Women experiencing urgency alone reported markedly better QoL compared to any other AI symptoms. AI appeared to have the strongest impact on the domains 'Coping' and 'Embarrassment'. Depression was only associated with experiencing the combination of all three symptoms [odds ratio (OR) 13; 95%confidence interval (CI) 3.2-51]. Experiencing flatus alone weekly or more was associated with the highest impact on 'Embarrassment' (OR 20; 95%CI 6.4-61) compared with all other symptoms or combination of AI symptoms, except the combination of all three AI symptoms. CONCLUSIONS: Between 3 and 10% of the primiparae in this material experienced AI to such a extent that it affected QoL. The greatest impact was seen in the QoL domain 'Coping'. These findings highlight the importance of an increased awareness of AI in late pregnancy among health professionals and the need to implement routine discussions about AI with expectant and new mothers.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study.

OBJECTIVE: To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery. DESIGN: Prospective population-based cohort study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 years or over. METHODS: Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI. RESULTS: Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9). CONCLUSION: One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.