Urgency as the cardinal symptom of overactive bladder: a critical analysis

Multivariate network meta-analysis incorporating class effects

BACKGROUND

Network meta-analysis synthesises data from a number of clinical trials in order to assess the comparative efficacy of multiple healthcare interventions in similar patient populations. In situations where clinical trial data are heterogeneously reported i.e. data are missing for one or more outcomes of interest, synthesising such data can lead to disconnected networks of evidence, increased uncertainty, and potentially biased estimates which can have severe implications for decision-making. To overcome this issue, strength can be borrowed between outcomes of interest in multivariate network meta-analyses. Furthermore, in situations where there are relatively few trials informing each treatment comparison, there is a potential issue with the sparsity of data in the treatment networks, which can lead to substantial parameter uncertainty. A multivariate network meta-analysis approach can be further extended to borrow strength between interventions of the same class using hierarchical models.

METHODS

We extend the trivariate network meta-analysis model to incorporate the exchangeability between treatment effects belonging to the same class of intervention to increase precision in treatment effect estimates. We further incorporate a missing data framework to estimate uncertainty in trials that did not report measures of variability in order to maximise the use of all available information for healthcare decision-making. The methods are applied to a motivating dataset in overactive bladder syndrome. The outcomes of interest were mean change from baseline in incontinence, voiding and urgency episodes. All models were fitted using Bayesian Markov Chain Monte Carlo (MCMC) methods in WinBUGS.

RESULTS

All models (univariate, multivariate, and multivariate models incorporating class effects) produced similar point estimates for all treatment effects. Incorporating class effects in multivariate models often increased precision in treatment effect estimates.

CONCLUSIONS

Multivariate network meta-analysis incorporating class effects allowed for the comparison of all interventions across all outcome measures to ameliorate the potential impact of outcome reporting bias, and further borrowed strength between interventions belonging to the same class of treatment to increase the precision in treatment effect estimates for healthcare policy and decision-making.

Personal goals and expectations of OAB patients in the UK

INTRODUCTION

In clinical practice and in research patient-centred outcomes are often utilised to help improve communication between patients and clinicians and to help manage expectations from treatment. However, many of these goals are generic and do not adequately capture the details of day to day life that bother patients the most and that they hope will improve with therapy. This study aimed to understand what are the goals of patients with overactive bladder symptoms in the UK who were taking part in a clinical trial and to assess goal achievement.

METHODS

This was a qualitative analysis of the patients goals recorded using the Self-Assessment Goal Achievement (SAGA) Questionnaire during the UK study assessing flexible dose fesoterodine in adults (SAFINA) trial. Free text patient goals were completed at baseline and an assessment of achievement was performed at the end of treatment. Grounded theory was used to develop themes and sub themes.

RESULTS

Three hundred and thirty-one patients completed the trial and 1137 open ended goals were set. Six themes emerged from the data including, OAB, other LUTS and finishing the task in hand with multiple subthemes noted.

CONCLUSIONS

By assessing and understanding what is important to the patient, it may help to tailor patient care and treatment and improve patient satisfaction.

Evaluating patients' symptoms of overactive bladder by questionnaire: the role of urgency in urinary frequency

OBJECTIVE

To explain what role urinary urgency has on urinary frequency in patients with overactive bladder (OAB).

MATERIALS AND METHODS

We prospectively enrolled 102 patients with OAB over a 6-week period. Patients were assessed with the OAB-q and a pilot questionnaire to identify which urinary symptoms were most bothersome and what underlying cause subjects attributed urinary frequency to. Associations between epidemiologic characteristics, OAB-q scores, and subject responses to the pilot questionnaire, were examined for statistical significance with the Pearson chi square test.

RESULTS

The study population comprised 85% women and 15% men, with mean age 67.4 years and mean OAB-q score 54. Subjects reported their most bothersome symptom was: frequency 24.5%, urgency or urgency incontinence 48.0%, nocturia 27.5%. Of the patients most bothered by frequency, 64% identified the International Continence Society definition of urgency or "fear of leakage" as the underlying reason for their frequency. Overall, 82.4% and 48.0% of patients reported urgency or urgency incontinence as a symptom and most bothersome symptom respectively. However, when patients were specifically asked what drives their urinary frequency, these percentages increased to 89.2% and 63.7%.

CONCLUSION

This pilot study confirms that urgency is a large factor underlying the drive to void frequently in OAB, even when patients do not admit to urgency as the most bothersome symptom.

Establishment of a protocol for large-scale gene expression analyses of laser capture microdissected bladder tissue

PURPOSE

Lower urinary tract symptoms (LUTS) can be caused by structural and functional changes in different compartments of the bladder. To enable extensive investigations of individual regions even in small bladder biopsies, we established a combination protocol consisting of three molecular techniques: laser capture microdissection microscopy (LCM), RNA preamplification and quantitative polymerase chain reaction (qPCR).

METHODS

Urinary bladders of ten mice were resected and frozen immediately or after a delay of 15 min. Cryosections were obtained and smooth muscle was isolated using the LCM technique. Then, RNA was extracted, including protocols with and without DNase digestion as well as with and without the addition of carrier RNA. Extracted RNA was either used for reverse transcriptase (RT)-PCR plus qPCR or for a combination of RNA preamplification and qPCR.

RESULTS

Our data showed that with RNA preamplification, 10 μg cDNA can be regularly generated from 2.5 ng RNA. Depending on expression levels, this is sufficient for hundreds of pPCR reactions. The efficiency of preamplification, however, was gene-dependent. DNase digestion before preamplification lead to lower threshold cycles in qPCR. The use of partly degraded RNA for RNA preamplification did not change the results of the following qPCR.

CONCLUSIONS

RNA preamplification strongly enlarges the spectrum of genes to be analyzed in distinct bladder compartments by qPCR. It is an easy and reliable method that can be realized with standard laboratory equipment. Our protocol may lead in near future to a better understanding of the pathomechanisms in LUTS.