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1.  The ACTIVE Cognitive Training Interventions and Trajectories of Performance among Older Adults 
Journal of aging and health  2012;25(0):10.1177/0898264312461938.
Salthouse (2006) illustrated that among Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized controlled trial participants, the pace of cognitive change over time accelerated for persons who had participated in training. Our goal was to determine if the pace of cognitive aging, net of effects due to practice, training, and loss of training gains, differed for persons who received training.
We evaluated change in cognitive performance over five years following brief cognitive training among older adults (N=1,659, age 65-94) in ACTIVE using a latent growth curve model.
Reasoning training, but not memory or speed, attenuated aging-related change. But this model modification produced instability and was not statistically significant. Memory gains were maintained throughout follow-up. About half of reasoning and speed gains were lost, however all trained groups performed better than controls at 5 years. 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.
Training can appear to accelerate age-related change, because change over time is coupled with loss of training gains. Of the three training interventions, only reasoning training appeared to attenuate the pace of normative decline. However, our analysis is limited by follow-up that is short for precisely characterizing aging-related change.
PMCID: PMC3866224  PMID: 23103453
Cognitive training interventions; Advanced Cognitive Training for Independent and Vital Elderly; training outcomes; growth curve modeling; older adults
2.  Risk Factors for Urinary Tract Infection following Incontinence Surgery 
International urogynecology journal  2011;22(10):1255-1265.
Introduction and Hypothesis
The purpose of this study is to describe risk factors for post-operative urinary tract infection (UTI) the first year after stress urinary incontinence surgery.
Multivariable logistic regression analyses were performed on data from 1,252 women randomized in two surgical trials, Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) and Trial Of Mid-Urethral Slings (TOMUS).
Baseline recurrent UTI (rUTI; ≥ 3 in 12 months) increased the risk of UTI in the first 6 weeks in both study populations, as did sling procedure and self-catheterization in SISTEr, and bladder perforation in TOMUS. Baseline rUTI, UTI in first 6 weeks, and PVR > 100 cc at 12 months were independent risk factors for UTI between 6 weeks and 12 months in the SISTEr population. Few (2.3-2.4%) had post-operative rUTI, precluding multivariable analysis. In women with pre-operative rUTI, successful surgery (negative cough stress test) at 1 year did not appear to decrease the risk of persistent rUTI.
Pre-operative rUTI is the strongest risk factor for post-operative UTI.
PMCID: PMC4184412  PMID: 21560012
Urinary tract infection; Stress urinary incontinence surgery; Recurrent urinary tract infection; Risk factors
3.  Relationship of Demographic and Health Factors to Cognition in Older Adults in the ACTIVE Study 
Journal of aging and health  2013;25(8 0):128S-146S.
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.
Baseline data from 2782 participants in the ACTIVE study were used to examine relationships of demographics and health conditions with composite scores of memory, reasoning, and speed of processing.
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.
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 affects on cognition.
PMCID: PMC4116102  PMID: 24385633
Cognitive functioning; Older adults; Cognitive aging; Memory; Reasoning; Speed
4.  Ten-Year Effects of the ACTIVE Cognitive Training Trial on Cognition and Everyday Functioning in Older Adults 
To determine the effects of cognitive training on cognitive abilities and everyday function over 10 years.
Design, Setting, and Participants
Ten-year follow-up of a randomized, controlled single-blind trial with 3 intervention groups and a no-contact control group. A volunteer sample of 2832 persons (mean baseline age, 73.6 years; 26% African American) living independently in 6 US cities.
Ten-session training for memory, reasoning, or speed-of-processing.; 4-session booster training at 11 and at 35 months after training.
Objectively measured cognitive abilities and self-reported and performance-based measures of everyday function.
Participants in each intervention group reported less difficulty with instrumental activities of daily living (IADL) (memory: effect size, 0.48 [99% 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 mean age of 82 years, about 60% of trained participants compared to 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]).
Each ACTIVE 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.
PMCID: PMC4055506  PMID: 24417410
cognitive training; elderly; cognitive abilities; everyday function; training maintenance
5.  Factors Associated With Quality Of Life In Women Undergoing Surgery For Stress Urinary Incontinence 
The Journal of urology  2010;184(6):2411-2415.
To determine the association of clinicodemographic factors with urinary incontinence (UI) related quality of life (QoL) in women having surgery for stress urinary incontinence (SUI) and to compare the incontinence-specific IIQ (Incontinence Impact Questionnaire) and the ICIQ (International Consultation on Incontinence Questionnaire). Secondary objectives evaluated the contributions of incontinence severity and sexual function to QoL.
Materials and Methods
Baseline data from 597 women in the Trial of Mid Urethral Slings (TOMUS). Correlates of QoL tested included health status and history, type, severity and bother of UI, and sexual function.
Lower QoL by both the IIQ and ICIQ included younger age, higher BMI, more SUI symptoms, and more severe and bothersome UI symptoms. Each measure identified factors associated with lower QoL not identified by the other (IIQ; Hispanic ethnicity, poor health status and more urge UI symptoms, and ICIQ; prior UI treatment and more UI episodes per day). Sexually active women had similar QoL but also increased incontinence episodes (IIQ and ICIQ) and more sexual dysfunction (IIQ only).
In women planning SUI surgery, QoL is associated with non-UI factors as well as with the type, severity and degree of bother from UI symptoms. Many factors are associated with QoL as measured by both IIQ and ICIQ. However more non-UI factors were associated with QoL when measured by the IIQ than by the ICIQ. More than one scale may be needed to evaluate QoL after SUI treatment.
PMCID: PMC3949527  PMID: 20952014
Urinary incontinence; Quality of life; Midurethral sling
6.  The ACTIVE Study: Study Overview and Major Findings 
Journal of aging and health  2013;25(8 0):3S-20S.
PMCID: PMC3934012  PMID: 24385638
7.  Risk Factors Associated with Urge Incontinence After Continence Surgery 
The Journal of urology  2009;182(6):2805-2809.
We identified pre-operative factors associated with bothersome UUI after incontinence surgery (Burch or sling).
Materials & Methods
Postoperative UUI was defined as treatment for UUI ≥ 6 weeks after surgery. Variables thought to affect postoperative UUI included: age, race, prior incontinence surgery or treatment, BMI, POP-Q stage, frequency of stress and urge symptoms, incontinence episode frequency, concomitant surgery, and urodynamic findings.
Bivariate logistic regression models were fit, in which each covariate was controlled for separately to ascertain potential importance. After controlling for surgery, the following baseline factors were associated with postoperative UUI (p<0.10) and included in multivariable modeling: age, BMI, prior incontinence surgery, prior anticholinergic medication, stress and urge symptom scores, detrusor overactivity (DO), and detrusor pressure-max flow.
665 who had surgical re-treatment for SUI 34 were excluded from the study. Participants had mean±SD age of 51±10. Stress and urge symptom scores were 19.3±4.6 and 6.4±3.9. 89 (14%) had prior incontinence surgery, and 165 (27%) had taken anticholinergic medication.
132 women (21%) required treatment for postoperative UUI (50 Burch, 82 sling). Odds of treatment for UUI after surgery were significantly higher after sling compared to Burch (OR 1.72, 95% CI 1.16, 2.54, p=0.007). A 10-point increase in pre-operative MESA urge score, prior anticholinergics, and DO all independently increased the odds of UUI.
Women are almost twice as likely to need treatment for postoperative UUI after sling than Burch. Women with preoperative urge, DO, or prior use of anticholinergic medications are more likely to have bothersome UUI, postoperatively.
PMCID: PMC3919632  PMID: 19837421
Urge incontinence; incontinence surgery; sling; detrusor overactivity; stress incontinence
8.  Condition Specific Quality of Life 24 Months After Retropubic and Transobturator Sling Surgery for Stress Urinary Incontinence 
To compare quality of life (QoL) and factors associated with QoL change after retropubic (RMUS) and transobturator (TMUS) midurethral slings using the Incontinence Impact Questionnaire, (IIQ) and the International Consultation on Incontinence Questionnaire (ICIQ).
Five hundred ninety seven women in a multicenter randomized trial of RMUS vs. TMUS were examined. The IIQ and ICIQ were obtained at baseline, 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 post- operative, controlling for treatment group and baseline QoL.
Improvement in IIQ was associated with: treatment success, younger age, improvement in stress 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 re-operation (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).
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.
PMCID: PMC3902543  PMID: 22983273
Urinary incontinence; Quality of life; Midurethral sling
9.  Moderating Perceptions of Bother Reports by Individuals Experiencing Lower Urinary Tract Symptoms 
Qualitative health research  2011;21(9):10.1177/1049732311405682.
We compared reports of symptom bother for the same urinary symptoms to understand why symptom severity and bother do not correspond in a straightforward manner. We used a grounded theory approach to analyze qualitative data from 123 individual interviews and developed a conceptual framework, identifying three symptom perceptions that might “moderate” symptom bother: causal, relative, and uncertainty. Symptom bother was lower for respondents who viewed symptoms causally (symptoms seemed explainable or “normal”) or relatively (urinary symptoms were compared to other symptoms or conditions). Bother tended to be higher for respondents who viewed symptoms with uncertainty (when symptom etiology and course were unknown). A greater portion of respondents in the causal perception group had not sought health care for their symptoms. This conceptual framework is useful for understanding the relationship between reactions to and health care-seeking for other symptoms.
PMCID: PMC3840894  PMID: 21483026
community and public health; health seeking; interviews; semistructured; qualitative analysis; sensitive topics
10.  Urodynamics, the supine empty bladder stress test, and incontinence severity 
Neurourology and urodynamics  2010;29(7):10.1002/nau.20836.
Determine whether urodynamic measures of urethral function [(valsalva leak point pressure (VLPP); maximal urethral closure pressure (MUCP); functional urethral length (FUL)] and the results of the supine empty bladder stress test (SEBST) correlate with each other and with subjective and objective measures of urinary incontinence (UI).
Data were collected preoperatively from subjects enrolled in a multicenter surgical trial of midurethral slings. Subjective measures included questionnaire scores from the Medical Epidemiological and Social Aspects of Aging questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Objective measures included a 24-hour pad weight test, incontinence episode frequency on a 3-day voiding diary, and a SEBST.
597 women enrolled. 372 women had valid VLPP values; 539 had valid MUCP/FUL values. Subjective measures of severity had weak to moderate correlation with each other and with objective measures of severity. VLPP and MUCP had moderate correlation with each other (r =0.36, p<0.001). Urodynamic measures of urethral function had little or no correlation with subjective or objective measures of severity. Subjects with a positive SEBST had more severe subjective and objective severity measures compared to the negative SEBST group, but they did not have significantly different VLPP and MUCP values.
VLPP and MUCP have moderate correlation with each other, but each had little or no correlation with subjective or objective measures of severity or with the results of the SEBST. This data suggests that the urodynamic measures of urethral function are not related to subjective or objective measures of UI severity.
PMCID: PMC3808883  PMID: 20127832
Correlation; empty bladder stress test; Maximum Urethral Closure Pressure (MUCP); severity; stress urinary incontinence; Valsalva Leak Point Pressure (VLPP)
11.  Characteristics of persons with overactive bladder of presumed neurologic origin: Results from the Boston Area Community Health (BACH) Survey 
Neurourology and urodynamics  2012;31(7):1149-1155.
To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB).
5,503 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 health care 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.
45 (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).
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.
PMCID: PMC3419809  PMID: 22674347
neurogenic bladder; epidemiology; overactive bladder
12.  Patient Satisfaction with Stress Incontinence Surgery 
Neurourology and urodynamics  2010;29(8):1403-1409.
To identify predictors and correlates of patient satisfaction 24 months after Burch colpopexy or autologous fascial sling for treatment of stress urinary incontinence (SUI).
Participants were the 655 randomized subjects in the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Variables potentially associated with satisfaction were tested in bivariate analysis, including demographics, baseline clinical characteristics of incontinence, and outcomes on validated subjective and objective measures. Satisfaction with treatment was defined as a response of “completely satisfied” or “mostly satisfied” on the Patient Satisfaction Questionnaire (PSQ) at 24 months. Variables significantly related to satisfaction were entered into multivariable regression models to test their independent association with satisfaction.
At 24 months post-surgery, 480 (73%) participants completed the PSQ. Mean (±SD) age of the sample was 52 (±10) years and 77% were white. Most (82%) were completely or mostly satisfied with their surgery related to urine leakage. In the final multivariable model, patient satisfaction was associated with greater reduction in SUI symptoms (from baseline to 24 months; OR=1.17, 95% CI:1.10, 1.24) and greater reductions in symptom distress (OR=1.16; CI:1.08, 1.24). Lower odds of satisfaction were associated with greater urge incontinence symptoms at baseline (OR=0.09, CI:0.04, 0.22), detrusor overactivity at 24 months (OR=0.29, CI:0.12, 0.69), and a positive stress test at 24 months (OR=0.45, CI:0.22, 0.91).
Stress incontinent women who also have urge incontinence symptoms may benefit from additional preoperative counseling to set realistic expectations about potential surgical outcomes or proactive treatment of urge incontinence symptoms to minimize their post-operative impact.
PMCID: PMC3732206  PMID: 20976815
patient outcomes assessment; patient satisfaction; surgery; urinary incontinence
13.  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.
PMCID: PMC3384749  PMID: 22400989
Cognitive training; Intervention; Aging; Dementia; Prevention; Cognition
14.  Qualitative Inquiry of Patient-Reported Outcomes: The Case of Lower Urinary Tract Symptoms 
Nursing Research  2012;61(4):283-290.
Patient-reported outcomes are a valuable tool for assessing healthcare, particularly for symptom-based conditions that lack definitive physiological measures of treatment efficacy.
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.
Semi-structured 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.
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.
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 health care 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.
PMCID: PMC3398610  PMID: 22565104
patient outcomes assessment; qualitative research; urinary tract symptoms
15.  Associations of commonly-used medications with urinary incontinence in a community-based sample 
The Journal of urology  2012;188(1):183-189.
To examine the association between use of medications and prevalence of urinary incontinence (UI) in gender-specific analyses of a community-based, representative sample.
Materials and Methods
A population-based epidemiologic study was conducted among 5,503 men and women aged 30-79 residing in Boston, Massachusetts (baseline data collected 2002-2005). Urologic symptoms were ascertained in a two-hour, in-person interview. UI was defined as urine leakage occurring weekly or more often, considering the past year. Medications used in the past month were considered ‘current use’. Associations of 20+ medications and prevalent UI were examined using multivariable logistic regression (odds ratios [ORs] and 95% confidence intervals [CIs]) with adjustments for known UI risk factors.
UI prevalence in the analysis sample was 9.0% in women and 4.6% in men. Among women, prevalence was highest among users of certain antihistamines (28.4%) and angiotensin II receptor blockers (ARBs) (22.9%). Among men, prevalence was highest among ARB (22.2%) and loop diuretic (19.1%) users. After final multivariable adjustment, there were significant positive associations for certain antihistamines, beta receptor agonists, ARBs, and estrogens with UI among women (all ORs >1.7), and a borderline-significant association for anticonvulsants (OR=1.75, 95% CI: 1.00, 3.07). Among men, only anticonvulsants (OR=2.50, 95% CI: 1.24, 5.03) were associated with UI after final adjustments, although ARBs showed an adjusted association of borderline significance (OR=2.21, 95% CI: 0.96, 5.10).
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 urologic symptoms.
PMCID: PMC3523747  PMID: 22591967
medications; urinary incontinence; pharmacoepidemiology; epidemiology
16.  Talking with Others About Stigmatized Health Conditions: Implications for Managing Symptoms 
Qualitative health research  2012;22(11):1468-1475.
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.
PMCID: PMC3666340  PMID: 22785624
communication; interviews; health seeking; relationships; symptom management
17.  Complementary and Alternative Therapies for Urinary Symptoms: Use in a diverse population sample qualitative study 
Urologic nursing  2012;32(3):149-157.
Study participants reported a range of remedies used to treat urinary symptoms, from popular products like saw palmetto to less commonly known remedies such as moabi. Many learned about remedies through social networks rather than from their primary care provider.
PMCID: PMC3662538  PMID: 22860393
Complementary and Alternative Therapies; Urinary Symptoms; Social Relationships and Health
18.  Patients' Experiences of Seeking Health Care for Lower Urinary Tract Symptoms 
Research in nursing & health  2011;34(6):496-507.
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.
PMCID: PMC3227388  PMID: 21898454
Help seeking; urinary symptoms; primary care; provider/patient communication; qualitative research
19.  A Randomized Trial of Urodynamic Testing before Stress-Incontinence Surgery 
The New England Journal of Medicine  2012;366(21):1987-1997.
Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes.
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.
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.
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; number, NCT00803959.)
PMCID: PMC3386296  PMID: 22551104
20.  Adverse Events Associated with Testosterone Administration 
The New England journal of medicine  2010;363(2):109-122.
Testosterone supplementation has been shown to increase muscle mass and strength in healthy older men. The safety and efficacy of testosterone treatment in older men who have limitations in mobility have not been studied.
Community-dwelling men, 65 years of age or older, with limitations in mobility and a total serum testosterone level of 100 to 350 ng per deciliter (3.5 to 12.1 nmol per liter) or a free serum testosterone level of less than 50 pg per milliliter (173 pmol per liter) were randomly assigned to receive placebo gel or testosterone gel, to be applied daily for 6 months. Adverse events were categorized with the use of the Medical Dictionary for Regulatory Activities classification. The data and safety monitoring board recommended that the trial be discontinued early because there was a significantly higher rate of adverse cardiovascular events in the testosterone group than in the placebo group.
A total of 209 men (mean age, 74 years) were enrolled at the time the trial was terminated. At baseline, there was a high prevalence of hypertension, diabetes, hyperlipidemia, and obesity among the participants. During the course of the study, the testosterone group had higher rates of cardiac, respiratory, and dermatologic events than did the placebo group. A total of 23 subjects in the testosterone group, as compared with 5 in the placebo group, had cardiovascular-related adverse events. The relative risk of a cardiovascular-related adverse event remained constant throughout the 6-month treatment period. As compared with the placebo group, the testosterone group had significantly greater improvements in leg-press and chest-press strength and in stair climbing while carrying a load.
In this population of older men with limitations in mobility and a high prevalence of chronic disease, the application of a testosterone gel was associated with an increased risk of cardiovascular adverse events. The small size of the trial and the unique population prevent broader inferences from being made about the safety of testosterone therapy.
PMCID: PMC3440621  PMID: 20592293
21.  Preoperative hesitating urinary stream is associated with postoperative voiding dysfunction and surgical failure following Burch colposuspension or pubovaginal rectus fascial sling surgery 
Introduction and hypothesis
We hypothesized that certain preoperative voiding symptoms would be correlated with poorer post-continence surgery outcomes in women.
Preoperative voiding symptoms from 655 women were assessed with questionnaires. Outcomes (overall failures, stress-specific failures, and voiding dysfunction) after Burch or sling surgery were measured. Logistic regression models were used to associate preoperative voiding symptoms with postoperative outcomes.
Hesitating urinary stream was associated with voiding dysfunction [OR 2.22, p=0.01], overall [OR 1.57, p=0.03], and stress-specific [OR 1.67, p=0.009] failures. A ten-point increase in preoperative Urogenital Distress Inventory-obstructive (UDI-O) subscore was associated with overall [OR 1.10, p=0.049] and stress-specific [OR 1.21, p<0.0001] failures. Even controlling for severity of POPQ stage, significant associations of hesitating urinary stream with voiding dysfunction, overall and stress-specific failures remained.
Preoperative hesitating urinary stream and obstructive voiding symptoms were associated with poorer surgical outcomes. Further studies in this area may be fruitful.
PMCID: PMC3098315  PMID: 21128068
Surgical outcome; Stress urinary incontinence; Voiding dysfunction; Voiding symptoms
22.  Race and Ethnic Differences in Health Beliefs about Lower Urinary Tract Symptoms 
Nursing research  2011;60(3):165-172.
Health beliefs are an important mediator between the experience of symptoms and health behaviors, and these beliefs can vary by race or ethnicity.
To better understand the gap between experiencing symptoms and not seeking medical care by studying health beliefs about lower urinary tract symptoms (LUTS) across race and ethnic groups.
Qualitative, semistructured interviews were conducted with 35 Black, Hispanic, and White people who reported at least one urinary symptom but had not spoken with a health care provider about the symptoms. Drawing on Shaw’s framework of health behavior and outcomes, a range of beliefs was examined: cause, consequence, continuation, and treatability. Interviews were transcribed, coded, and analyzed for themes according to race or ethnic background.
The belief that LUTS are a typical part of aging and not amenable to medical treatment was most common among White respondents. Black respondents more commonly attributed their symptoms to personal behaviors over which they had control and therefore did not require medical care. Hispanic respondents appeared more often to live with uncertainty about the cause of their symptoms and an accompanying concern about a future health consequence.
The combination of a range of health beliefs to form a cognitive representation made sense of the behavior of not seeking medical care. The finding that sociocultural differences shaped these cognitive representations underscores the need for cultural competency in patient assessment and education. Results have implications for theories of health behavior and indicate further research with larger samples, additional psychosocial influences, and other symptoms.
PMCID: PMC3142927  PMID: 21522033
cognitive aspects; cultural competency; health behavior; urinary tract
23.  Depressive Symptoms Impair Everyday Problem-Solving Ability through Cognitive Abilities in Late Life 
The association between depression and functional disability in late life remains unclear. This study aimed to explore the relationship between depressive symptoms and daily functioning through the mediation of cognitive abilities, measured by memory, reasoning, and speed of processing.
We recruited 2,832 older adults (mean age = 73.6 years, SD = 5.9) participating in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study. Structural equation modeling (SEM) was applied to illustrate the relationship between depressive symptoms and everyday problem-solving ability through the mediation of cognitive abilities.
Depressive symptoms were associated with impaired everyday problem-solving ability directly and indirectly mediated via learning and memory, and reasoning. Although depressive symptoms were associated with speed of processing, speed of processing was not significantly related to everyday problem-solving ability.
This study conceptualizes the possible relationships between depressive symptoms and daily functioning with mediation of cognitive abilities and provides a feasible model for the prevention of functional impairment related to geriatric depressive symptoms.
PMCID: PMC3000466  PMID: 20808123
depression; cognition; everyday function; elderly
24.  Fluid manipulation among individuals with lower urinary tract symptoms: a mixed methods study 
Journal of clinical nursing  2010;20(1-2):156-165.
Aims and objective
To determine, qualitatively and quantitatively, how individuals use fluid manipulation to self-manage the urinary symptoms of daytime frequency, urgency and urine leakage and the underlying rationale for this behaviour.
Lower urinary tract symptoms are prevalent and burdensome, and little is known about how individuals with lower urinary tract symptoms manipulate their fluid intake.
A mixed methods design included statistical analysis of data from a population-based survey of urologic symptoms and qualitative analysis of in-depth interviews.
Quantitative data came from 5503 participants of the baseline Boston Area Community Health Survey, a population-based, random sample epidemiologic survey of urologic symptoms. Qualitative data came from in-depth interviews with a random subsample from Boston Area Community Health of 152 black, white and Hispanic men and women with LUTS.
Qualitative data showed that some respondents restricted fluid intake while others increased it, in both cases with the expectation of improved symptoms. Quantitative data showed that fluid intake was greater in men and women reporting frequency (p < 0·001). Women with frequency drank significantly more water (p < 0·001), while women with urgency drank significantly less water (p = 0·047).
This study found divergent expectations of the role of fluids in alleviating symptoms, leading some individuals to restrict and others to increase fluid intake. Individuals with lower urinary tract symptoms may need guidance in fluid management.
Relevance to clinical practice
Nurses should be aware that patients may self-manage lower urinary tract symptoms by restricting fluid intake, putting them at risk for dehydration, constipation and urinary tract infection, but also that they may be increasing their fluid intake, which could worsen symptoms. This study pinpoints a specific area of need among patients with lower urinary tract symptoms and provides a practical opportunity for nurses to assist their patients with behavioural and fluid management by emphasising the clinical guidelines.
PMCID: PMC3039788  PMID: 21073582
behaviour; care needs; coping; lower urinary tract symptoms; mixed methods; qualitative approaches; self-management
25.  Beyond incontinence: The stigma of other urinary symptoms 
Journal of advanced nursing  2010;66(11):2460-2470.
This paper is a report of a study conducted to characterize the stigma of urinary frequency and urgency and differentiate it from the stigma of incontinence and to describe race/ethnic and gender differences in the experience of stigma among a diverse sample of individuals.
Lower urinary tract symptoms, including frequency, urgency and incontinence, are susceptible to stigma, but previous stigma research has focused almost exclusively on incontinence.
The Boston Area Community Health Survey is a population-based, random sample epidemiological survey of urologic symptoms (N=5503). Qualitative data for this study came from in-depth interviews conducted between 2007 and 2008 with a random subsample of 151 black, white and Hispanic men and women with urinary symptoms.
Respondents reported stigma associated with frequency and urgency – not just incontinence. The stigma of frequency/urgency is rooted in social interruption, loss of control of the body, and speculation as to the nature of a non-specific “problem.” Overall, the stigma of urinary symptoms hinged upon whether or not the problem was “perceptible.” Men felt stigmatized for making frequent trips to the bathroom and feared being seen as impotent. Women feared having an unclean body or compromised social identity. Hispanic people in particular voiced a desire to keep their urinary symptoms a secret.
The stigma of urinary symptoms goes beyond incontinence to include behaviors associated with frequency and urgency. Healthcare practitioners should assess for stigma sequelae (e.g. anxiety, depression) in individuals with frequency and urgency, and stress treatment options to circumvent stigmatization.
PMCID: PMC3032268  PMID: 20735505
Nursing; healthcare professionals; stigma; public health; urinary incontinence; urinary symptoms

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