Understanding the consumption of folic acid during preconception, among Pakistani, Bangladeshi and white British mothers in Luton, UK: a qualitative study

Background To review the similarities and differences in Pakistani, Bangladeshi and White British mothers health beliefs (attitudes, knowledge and perceptions) and health behaviour regarding their consumption of folic acid pre-conception, to reduce the risk of neural tube defects. Methods Our study used a descriptive qualitative research approach, implementing face-to-face focus group discussions with Pakistani, Bangladeshi or White British mothers (normal birth outcomes and mothers with poor birth outcomes) and semi-structured interviews or focus groups with service providers using semi-structured topic guides. This method is well suited for under researched areas where in-depth information is sought. There were three sample groups: 1. Pakistani, Bangladeshi and White British mothers with normal birth outcomes (delivery after 37 weeks of gestation, in the preceding 6 to 24 months, weighing 2500 g and living within a specified postcode area in Luton, UK). 2. Pakistani Bangladeshi and white British bereaved mothers who had suffered a perinatal mortality (preceding 6 to 24 months, residing within a specificied postcode area). 3. Healthcare professionals working on the local maternity care pathway (i.e. services providing preconception, antenatal, antepartum and postpartum care). Transcribed discussions were analysed using the Framework Analysis approach. Results The majority of mothers in this sample did not understand the benefits or optimal time to take folic acid pre-conception. Conversely, healthcare professionals believed the majority of women did consume folic acid, prior to conception. Conclusions There is a need to increase public health awareness of the optimal time and subsequent benefits for taking folic acid, to prevent neural tube defects.</p

Increased risk of laryngeal and pharyngeal cancer after gastrectomy for ulcer disease in a population-based cohort study

BACKGROUND: Gastrectomy has been indicated as a risk factor for laryngeal cancer, and possibly also for pharyngeal cancer, but few studies are available. The postulated mechanism is increased bile reflux following gastrectomy. METHODS: This was a population-based cohort study of patients who underwent gastrectomy for peptic ulcer disease between 1964 and 2008 in Sweden. Follow-up data for cancer was obtained from the Swedish Cancer Register. Relative risk was calculated as standardised incidence ratios (SIRs) with 95% confidence intervals (CIs). RESULTS: The gastrectomy cohort comprises 19 767 patients, contributing 348 231 person-years at risk. The observed number of patients with laryngeal (n = 56) and pharyngeal cancer (n = 28) was two-fold higher than the expected (SIR: 2.0, 95% CI: 1.5-2.6 and SIR: 2.4, 95% CI: 1.6-3.5, respectively). After exclusion of 5536 cohort members with tobacco- or alcohol-related disease, the point SIRs remained increased (SIR: 1.6, 95% CI: 1.1-2.2 and SIR: 1.7, 95% CI: 0.9-2.8, respectively). The SIRs of laryngeal and pharyngeal cancer increased with time after gastrectomy (P for trend = 30 years after gastrectomy (SIR: 4.8, 95% CI: 2.1-9.5 and SIR: 10.2, 95% CI: 3.7-22.3, respectively). CONCLUSION: Gastrectomy for peptic ulcer disease might entail a long-term increased risk of laryngeal and pharyngeal cancer

A Smartphone app For Self-Management of Urgency and Mixed Urinary Incontinence : a Randomized Controlled Trial

Hypothesis / aims of study: Urgency (UUI) and mixed (MUI) urinary incontinence are common clinical problems. They account for almost half of all cases of urinary incontinence (UI) in women [1], and have a potentially large impact on quality of life. Nonetheless, many women are reluctant to seek treatment, sometimes due to UI being a stigmatized condition. The recommended first-line treatment for UUI and MUI is pelvic floor muscle training (PFMT) and lifestyle advice [2], with bladder training as a valuable complement to the treatment. Previous studies have shown that a smartphone app was an effective form of self-management for women with stress urinary incontinence (SUI), both in terms of treatment efficacy [3] and cost-effectiveness. On-going studies show promising results of the app once it was made freely available for download, and a further study of the user experience of the app found that the app provided an appreciated and satisfactory experience. In this study, we aimed to evaluate whether a new smartphone app for the self-management of UUI and MUI in women was effective, in comparison to app-based information only. Study design, materials and methods: Between April 2017 and March 2018, women were consecutively recruited to this randomized controlled trial (RCT) via a screening questionnaire on the homepage of the research project. The trial has been Clinical Trials registered. The inclusion criteria were as follows: woman (gender self-stated and sex assigned at birth), ≥18 years, UUI or MUI with ≥2 leakages/week and ≥12 months of symptom duration. Pregnant women or women who used another PFMT app or anti-muscarinic drugs were not eligible to participate in the study. In order to identify and redirect cases that were better suited to receive usual care, an algorithm was developed by a team of professionals with both clinical and scientific experience from fields such as urogynecology, general practice, urology and incontinence care. The algorithm included questions on the person’s history of cancer in the pelvic region, diabetes, and neurological symptoms and diseases, as well as questions on certain alarm symptoms (e.g. painful urges, dysuria, haematuria, metrorrhagia, recurring urinary tract infections, bladder-emptying difficulties and pyelonephritis). The presence of any alarm symptom led to the respondent being classified as not eligible for the study and instead recommended to contact their usual medical care provider. Women who passed the screening questionnaire and submitted an email address received information about the study, and were asked to fill in an Informed Consent form, a two-day bladder diary and a baseline questionnaire which included the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), which provides a validated UI symptom score (range 0 - 21 points) with questions on frequency, amount and overall impact. Respondents were then contacted by telephone for an interview during which the symptom-based diagnosis of UUI or MUI was determined, and questions about alarm symptoms and UI symptoms were asked to ensure that the respondent was truly eligible for the study. Throughout the study, there was no face-to-face contact between the research group and the participants, only communication by email and telephone. The participants were randomized 1:1 to the two groups using sealed opaque envelopes prepared by an independent administrator who generated the randomization plan via the online randomization tool at http://www.randomization.com. Women randomized to the intervention group received access to the Treatment App, a smartphone app built on four themes: PFMT; bladder training; psychological education; and lifestyle information (Figure 1). The PFMT and bladder training parts of the app included 11-step and 7-step training programmes, respectively, in addition to information on pelvic floor anatomy and bladder physiology. The psychological education contained information on psychological topics related to UI, and three optional exercises. The Treatment App also offered an option to set three different times for reminder notifications, as well as an automated feedback function. In addition, the app included individual advice based on information from questionnaires and the bladder diary. The advice was generated via a pre-designed template and offered guidance to the most relevant parts of the app for each user. The control group received access to the Information App, a very limited version of the app, containing only brief information on the different topics and no training programmes or other features. Three months after randomization, the participants were asked to fill in a follow-up questionnaire and another bladder diary. In this abstract we present the results of the analysis of the primary outcome measure, the ICIQ-UI SF, measured at baseline and follow-up. Analyses of secondary outcomes, including incontinence episode frequency, are currently on-going and will be presented at a later date. Sample size calculation: Based on the findings of previous studies, improvements in the ICIQ-UI SF of 2.5 points in the Treatment App group and 0.9 points in the Information App group were assumed. To detect this difference with 80% power, 2-side test and a significance of 0.05, a sample size of 49 women was needed in each group. To allow for a dropout rate of 20%, each group needed to include 60 participants, and we therefore aimed to recruit 120 women in total. Statistical analysis: We performed Intention to Treat analysis by using a linear mixed model to estimate the difference between the groups in the ICIQ-UI SF at follow-up. A paired t-test was used for within-groups comparisons of the mean ICIQ-UI SF scores at baseline and follow-up. Results: 123 women were randomized to receive the Treatment App (n=60) or the Information App (n=63). The groups did not differ significantly in baseline measures (e.g. age, BMI, education level) nor in the mean ICIQ-UI SF scores. The mean age was 58.30 (SD 9.55) years and the mean BMI was 26.17 (SD 4.47) kg/m². The symptom-based diagnosis of MUI was more common (n=88) than that of UUI (n=35), and this distribution was equal across the two groups. The majority of women had moderate (n=73), severe (n=43) or very severe (n=4) incontinence, based on the ICIQ-UI SF scores. Two women, both in the Treatment App group, were lost to follow-up. Participants in both groups improved with regard to the mean ICIQ-UI SF score at follow-up (Treatment App group -4.67 (-5.65 to -3.69, 95% CI, p <0.001) and Information App group -1.64 (-2.31 to -0.96, 95% CI, p <0.001)). The improvement was significantly larger in the Treatment App group (p = 0.001) (Figure 2). Interpretation of results: Self-management of UUI or MUI using a mobile app led to highly significant improvements in incontinence symptoms with a significant difference compared to a control group. Thus the findings in this study show that the use of an app that includes treatment with PFMT, bladder training, psychological education and lifestyle advice was effective for women with UUI or MUI. Concluding message: Previous studies have shown that a smartphone app is an effective, easily accessible and appreciated first-line treatment option for women with SUI. The findings in the current study indicate that, provided that certain alarm symptoms or risk factors are not present, a smartphone app may be a useful addition to first-line treatment options for women with UUI or MUI who are interested in eHealth self-management

A mobile app for self-management of urgency and mixed urinary incontinence in women : Randomized controlled trial

Background: Many women experience urgency (UUI) and mixed (MUI) urinary incontinence but commonly hesitate to seek care. Treatment access and self-management for these conditions can be supported through eHealth approaches. Objective: This study aimed to investigate the efficacy of the mobile app Tät II for self-management of UUI and MUI in women. Methods: This randomized controlled trial included women ≥18 years old with UUI or MUI and ≥2 leakages per week. Those with red-flag symptoms were excluded. Participants were recruited via analog and digital advertisements and screened for initial selection through a web-based questionnaire. Data were collected using another questionnaire and a 2-day bladder diary. A telephone interview confirmed the symptom diagnosis. Participants were randomized (1:1) to receive access to a treatment app (including pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, tailored advice, exercise log, reinforcement messages, and reminders) or an information app (control group), with no external treatment guidance provided. The primary outcome was incontinence symptoms at the 15-week follow-up, measured using the International Consultation on Incontinence Questionnaire (ICIQ)-Urinary Incontinence Short Form (ICIQ-UI SF). Urgency symptoms were assessed using the ICIQ-Overactive Bladder Module (ICIQ-OAB) and quality of life using the ICIQ-Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol). Incontinence episode frequency (IEF) was calculated per bladder diary entries. Improvement was measured using the Patient's Global Impression of Improvement. All outcomes were self-reported. Cure was defined as no leakages per the bladder diary. Intention-to-treat analysis was performed. Results: Between April 2017 and March 2018, 123 women (mean age 58.3, SD 9.6 years) were randomized to the treatment (n=60, 2 lost to follow-up) or information (n=63) group. Of these, 35 (28%) women had UUI, and 88 (72%) had MUI. Mean ICIQ-UI SF score at follow-up was lower in the treatment group than in the information group (estimated difference -3.1, 95% CI -4.8 to -1.3). The estimated between-group difference was -1.8 (95% CI -2.8 to -0.99) for mean ICIQ-OAB score and -6.3 (95% CI -10.5 to -2.1) for the mean ICIQ-LUTSqol score at follow-up. IEF reduction from baseline to follow-up was greater in the treatment group (-10.5, IQR -17.5 to -3.5) than in the information group (P&lt;.001). Improvement was reported by 87% (52/60) of treatment group participants and by 30% (19/63) of information group participants. The cure rate was 32% in the treatment group, and 6% in the information group (odds ratio 5.4, 95% CI 1.9-15.6; P=.002). About 67% (40/60) of the treatment group participants used the app more than thrice a week. Conclusions: The treatment app was effective for improving urgency and mixed incontinence in women. When self-management is appropriate, this app may be a good alternative to pharmacological treatment or other conservative management, thus increasing access to care.