Determining the Health Utility of Urinary Incontinence in Women

Objective The goal of this study was to define the utility of urinary incontinence in women using the Standard Gamble, the gold standard method for determining health state utilities, based on a diagnosis obtained from multichannel urodynamic testing, the gold standard in clinical diagnosis. Background Health state utility values are important in many areas of medical research. The values are used in cost-utility analysis, decision analysis and health related quality of life studies. To date, studies that have estimated the utility of urinary incontinence in women have relied on values from generic health related quality of life questionnaires such as the ED-5Q and Health Utilities Index or from expert opinion. The utility of urinary incontinence in these studies appears to be unintuitivelylow, at 0.71 to 0.82, with perfect health represented by 1.0. The utility of health states that are much more debilitating, for example cancer (0.82), is higher than urinary incontinence. These studies have relied on patient self-diagnosis of incontinence. Additionally, they have considered all types of urinary incontinence together. Intuitively, one would think that quality of life would be affected differently with different types (stress, urge, mixed) and differing severity of incontinence. Methods All adult female patients who underwent urodynamic testing at Brigham and Women’s Hospital were prospectively recruited. Diagnosis of type of incontinence was made by attending physician interpretation of the urodynamic study. No exclusion criteria. Patients completed three validated questionnaires: Sandvik Severity Index - A validated two question symptom specific instrument to evaluate urinary incontinence EQ-5D -A five-domain generic quality of life questionnaire. Answers are converted into a utility value. Visual Analog Scale - Vertical line from 0 (worst imaginable health) to 100 (best imaginable health). Patient rates own perception of health on line. The Standard Gamble technique was used in a standard format to determine each patient’s utility value for their health state. Patient is asked to choose between life in current health state and varying risks of immediate painless death. Gold Standard method to determine patients utility preference for their health state. Results This pilot study of 28 patients demonstrated a significant difference in utility value derived from the Standard Gamble and the generic health-related quality of life instruments. There were 21 patients with stress urinary incontinence, 6 patients with urge urinary incontinence and 1 patient with mixed urinary incontinence. Mean Sandvik score was higher in Urge Incontinence subgroup. Mean Utility from Standard Gamble was lower in Urge Incontinence group. Sandvik scores were moderately correlated with EQ-5D, SG and VAS utilities. Conclusions Utility scores derived from Standard Gamble were significantly higher than those derived from generic health related quality of life instruments. Utility scores derived from EQ-5D and VAS were similar tothose previously reported in the literature. Current utility values over-estimate the degree of bother of urinary incontinence. Researchers should consider using higher utility values for urinary incontinence in future cost utility and quality of life studies

Orthopedic Back to Basics: Improving Total Joint Replacement Metrics in a Specialized Patient Population

Aim: Neurovascular checks following total hip and knee arthroplasty is a Joint Commission standard for all certified programs. Accurate and timely completion of these checks can be difficult in the Michigan Department of Corrections (MDOC) population. This is mainly due to the logistics of the unit and lower volume of cases compared to the non-MDOC population. The main goal of this quality improvement project was to increase completion compliance of neurovascular checks in the MDOC population at Henry Ford Jackson Hospital (HFJH). Plan: In 2022 on average 4 patients from MDOC received a total hip or knee arthroplasty a month which is much less than the orthopedic unit where on average of 11 patients a month stay post op following their total hip or knee arthroplasty. Currently the standard of care for patients post total hip or knee arthroplasty is that neurovascular checks are completed by the Registered Nurse (RN) at intervals of q1 hours x 4 hours, and then q4 hours for 24 hours following surgery and then q shift for the remained of their hospitalization. Completion of neurovascular checks is monitored monthly and shared at the HFJ Joint Excellence Committee & HFJ Joint Operations Committee. The low volume of MDOC patients is a barrier to the nursing staff in completing the neurovascular checks accurately and timely. Currently RNs who are hired on the MDOC secured unit at HFJH receive training on neurovascular checks via an e learning module through our learning management system Cornerstone & with their preceptor during orientation. Do: The Clinical Nurse Specialist and Clinical Educator from the orthopedic unit held interactive and simulation based learning sessions in early October. These educational sessions were for all registered nurses working on the MDOC secure unit. Each session included a presentation from one of the Orthopedic Advanced Practice Providers (APP) reviewing post op standards of care and possible complications, the hardware used for joint replacement at HFJH and a simulation of caring for a post operative patient. Check: In quarter 1 of 2022 completion percentage of neurovascular audits in the MDOC population was 37%. In quarter 2 and quarter 3 completion percentage was 34%. The interactive education took place with the MDOC secure unit staff in early quarter 4 of 2022. The final completion percentage for quarter 4 was 61%. The completion percentage for quarter 1 2023 will be determined in early April. Act: The completion percentages will continue to be monitored both monthly and quarterly to ensure the intervention continues to be successful Collaboration between CNS, Clinical Educator & Nurse Manager will occur monthly to review data, along with ensuring programs are put into place for newly hired RNs. Continue to offer interactive education yearly for staff caring for patients post total hip and knee arthroplasty. Keys to Success: In person training was a better reinforcement method for compliance instead of other avenues that have been used over the last few years. Simulation provided an avenue for the RNs to ask questions and receive immediate feedback. Multidisciplinary education provided a full picture to the staff who care for these patients but not as regularly as the orthopedic unit nurses.https://scholarlycommons.henryford.com/nursresconf2023/1006/thumbnail.jp

Understanding Health Utilities in Women with Urinary Incontinence

Objectives: The purpose of this study was to compare the health utility of UI in women as derived from the EQ-5D with the gold standard, the Standard Gamble. The secondary aim of this study was to compare health utility values of affected patients to healthy controls. Materials and Methods: Clinical diagnosis was categorized as normal, stress, mixed or urge urinary incontinence. Healthy controls were read a scenario for stress or mixed UI. All subjects completed the Sandvik Severity Index (SSI), EQ-5D, and Standard Gamble (SG) conversation. Results: 50 healthy controls and 119 affected subjects were recruited. The mean utility value for incontinence varied based on method: EQ-5D (0.78 + 0.17) and SG (0.85 + 0.20). There was a significant difference between utility scores derived from SG and EQ-5D (p=0.0004). This significant difference was maintained in the subset of women with SUI: EQ-5D (0.81 + 0.16), SG (0.87 + 0.18), p=0.028; but not in women with MUI or UUI. When comparing healthy controls to women with SUI, there were significant differences in the utility values derived by SG (0.76 + 0.26 vs. 0.87 + 0.18, p=0.07) but not by EQ-5D. When comparing healthy controls to women with MUI, there was also a significant difference in the utility derived by SG (0.92 + 0.10 vs. 0.75 + 0.21, p=0.01) but not by EQ-5D. SSI scores moderately correlated with SG utility values and strongly correlated with EQ-5D utility values. Logistic regression analysis showed that utility values were unaffected by age and menopausal status. Conclusion: This study suggests that using the EQ-5D to quantify the utility of UI may over-estimate the degree of bother when compared to SG assessment. This is important because the SG process more closely approximates the decision to undergo surgery. Relying on the EQ-5D to assess health utilities in women with UI may not be valid

Sexuality Curriculum Policies: Rural is Not Always More Conservative

This study examined sexuality education policies of school districts following the enactment of a law by the state of Iowa in 2007 requiring schools to include curriculum related to human growth and development education. The authors compared responses from superintendents in rural and urban areas in the state of Iowa regarding their districts’ sexuality curriculum policies. All public school superintendents in Iowa (n=364) were mailed a survey; 131 (36%) responded. The sample was representative of the state both geographically and by size of district. Findings indicate that while rural states (or more-rural areas within rural states) may be publically perceived to be more conservative than urban areas, their sexuality education policies show little statistical difference. Additionally, Iowa’s sexuality education policies were found to be equally or more inclusive in comparison to previously reported national results. Community opposition to sexuality education was not evident. Superintendents indicated that state directives were the most influential factor driving district policies on sexuality education

Autophagy in Idiopathic Pulmonary Fibrosis

Background: Autophagy is a basic cellular homeostatic process important to cell fate decisions under conditions of stress. Dysregulation of autophagy impacts numerous human diseases including cancer and chronic obstructive lung disease. This study investigates the role of autophagy in idiopathic pulmonary fibrosis. Methods: Human lung tissues from patients with IPF were analyzed for autophagy markers and modulating proteins using western blotting, confocal microscopy and transmission electron microscopy. To study the effects of TGF-β1 on autophagy, human lung fibroblasts were monitored by fluorescence microscopy and western blotting. In vivo experiments were done using the bleomycin-induced fibrosis mouse model. Results: Lung tissues from IPF patients demonstrate evidence of decreased autophagic activity as assessed by LC3, p62 protein expression and immunofluorescence, and numbers of autophagosomes. TGF-β1 inhibits autophagy in fibroblasts in vitro at least in part via activation of mTORC1; expression of TIGAR is also increased in response to TGF-β1. In the bleomycin model of pulmonary fibrosis, rapamycin treatment is antifibrotic, and rapamycin also decreases expression of á-smooth muscle actin and fibronectin by fibroblasts in vitro. Inhibition of key regulators of autophagy, LC3 and beclin-1, leads to the opposite effect on fibroblast expression of á-smooth muscle actin and fibronectin. Conclusion: Autophagy is not induced in pulmonary fibrosis despite activation of pathways known to promote autophagy. Impairment of autophagy by TGF-β1 may represent a mechanism for the promotion of fibrogenesis in IPF

The Future of the New International Tax Regime

TesisObjetivo: Determinar el nivel de conocimiento sobre las infecciones de transmisión sexual - VIH/SIDA y sus medidas preventivas en estudiantes de la Facultad de Ciencias de la Salud - UNSCH. Marzo - junio del 2018. Material y métodos: Se realizó un estudio de tipo: Aplicada, con diseño: descriptivo, prospectivo, transversal, comparativo. Muestra: 310 estudiantes de la Facultad de Ciencias de la Salud, que conformaron 93 estudiantes de obstetricia, 40 estudiantes de medicina humana, 90 estudiantes de enfermería y 87 estudiantes de farmacia y bioquímica, matriculados en el semestre académico 2018-I; la técnica fue la encuesta y como instrumento el cuestionario. Los datos obtenidos fueron almacenados y procesados en elpaquete estadístico SPSS 22.0 G, para el análisis de datos se utilizó el método de la escala de Stanones, así determinar el nivel de conocimiento, para la comparación de la hipótesis se utilizó el análisis de varianza (ANOVA) y la prueba de Tukey, para el nivel de confiabilidad se utilizó el chi cuadrado, siendo P 3 asignaturas que incluyen contenidos de las ITS, tienen un nivel de conocimiento medio con un 71.90% y alto con un 21.90%, en relación a los que llevaron ≤3 asignaturas tienen nivel de conocimiento medio con un 63.70% y bajo con un 28.10%; el 71. 40% del sexo masculino y 62.50% el sexo femenino tienen un nivel de conocimiento medio. En la dimensión del nivel de conocimiento sobre las ITS - VIH/SIDA, el 64.50% de estudiantes tienen el nivel de conocimiento medio, siendo el 87.50% en medicina humana, el 65.60% en obstetricia, el 61.10% en enfermería y el 50.60% en farmacia y bioquímica; habiendo diferencia estadísticamente significativa de obstetricia respecto a farmacia y bioquímica; medicina humana respecto a enfermería y farmacia y bioquímica. En la dimensión de medidas preventivas de las ITS - VIH/SIDA, 60.30% tienen un nivel de conocimiento medio, siendo el 76.80% en farmacia y bioquímica, el 65.60% en obstetricia, 53.30% en enfermería y 47.50% medicina humana; no habiendo diferencia estadísticamente significativa. Desconocen el tratamiento de las ITS - VIH/SIDA, los signos y síntomas, el agente causal y patógeno, del mismo modo ocurre de las fases del VIH, las complicaciones de las ITS - VIH/SIDA y las medidas preventivas. Conclusiones: Los estudiantes de la Facultad de Ciencias de la Salud tienen un nivel de conocimiento medio de las ITS - VIH/SIDA y sus medidas preventivas, el número de asignaturas influye en el nivel de conocimiento, el sexo no influye en el nivel de conocimiento. Habiendo diferencias estadísticamente significativas

Liver-directed treatments of liver-dominant metastatic leiomyosarcoma

PURPOSEThe purpose of this study was to determine the safety and efficacy of liver-directed therapies in patients with unresectable metastatic leiomyosarcoma to the liver. Liver-directed therapies included in this study were transarterial chemoembolization with doxorubicin eluting beads (DEB-TACE), yttrium-90 (Y90) radioembolization, and percutaneous microwave ablation.METHODSThis is a single institution retrospective study of unresectable metastatic leiomyosarcoma to the liver treated with DEB-TACE, radioembolization, or microwave ablation. DEB-TACE was performed using 70–150 or 100–300 µ doxorubicin-loaded drug-eluting LC beads. Radioembolization was performed using Y90 glass microspheres. Electronic medical records were retrospectively reviewed to evaluate clinical and biochemical toxicities, tumor response on imaging, overall survival (OS), and liver progression-free survival (PFS).RESULTSA total of 24 patients with metastatic leiomyosarcoma to the liver who underwent liver-directed treatment were identified (8 males, 16 females; average age, 62.8±11.4 years). Of these patients, 13 underwent DEB-TACE, 6 underwent Y90, and 5 underwent ablation. Three patients received a combination of treatments: one received Y90 followed by DEB-TACE, one received ablation followed by DEB-TACE, and one received ablation followed by Y90. Of the 24 patients, 19 received prior chemotherapy. At 3-month follow-up, grade 1 or 2 lab toxicities were found in 20 patients; 3 patients had grade 3 toxicities. A grade 3 clinical toxicity was reported in one patient. MELD score was 7.5±1.89 at baseline and 8.8±4.2 at 3 months. Median OS was 59 months (95% CI, 39.8–78.2) from diagnosis, 27 months (95% CI, 22.9–31.0) from development of liver metastasis, and 9 months (95% CI, 0–21.4) from first liver-directed treatment. Median liver PFS was 9 months (95% CI, 1.4–16.6).CONCLUSIONTreatment with liver-directed therapies for patients with unresectable metastatic leiomyosarcoma to the liver is safe and can improve overall survival, with OS after liver-directed therapy being similar to patients who underwent surgical resection

Epithelial Cell Mitochondrial Dysfunction and PINK1 Are Induced by Transforming Growth Factor- Beta1 in Pulmonary Fibrosis

Background: Epithelial cell death is a major contributor to fibrogenesis in the lung. In this study, we sought to determine the function of mitochondria and their clearance (mitophagy) in alveolar epithelial cell death and fibrosis. Methods: We studied markers of mitochondrial injury and the mitophagy marker, PTEN-induced putative kinase 1 (PINK1), in IPF lung tissues by Western blotting, transmission electron microscopy (TEM), and immunofluorescence. In vitro experiments were carried out in lung epithelial cells stimulated with transforming growth factor-β1 (TGF-β1). Changes in cell function were measured by Western blotting, flow cytometry and immunofluorescence. In vivo experiments were performed using the murine bleomycin model of lung fibrosis. Results: Evaluation of IPF lung tissue demonstrated increased PINK1 expression by Western blotting and immunofluorescence and increased numbers of damaged mitochondria by TEM. In lung epithelial cells, TGF-β1 induced mitochondrial depolarization, mitochondrial ROS, and PINK1 expression; all were abrogated by mitochondrial ROS scavenging. Finally, Pink1-/- mice were more susceptible than control mice to bleomycin induced lung fibrosis. Conclusion: TGF-β1 induces lung epithelial cell mitochondrial ROS and depolarization and stabilizes the key mitophagy initiating protein, PINK1. PINK1 ameliorates epithelial cell death and may be necessary to limit fibrogenesis

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy