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Lai HH, Rutlin J, Smith AR, Helmuth ME, Hokanson JA, Yang CC, Clemens JQ, Magnotta VA, Bretschneider CE, Kenton K, DeLancey JOL, John K, Kirkali Z, Shimony JS. Structural Changes in Brain White Matter Tracts Associated With Overactive Bladder Revealed by Diffusion Tensor Magnetic Resonance Imaging: Findings From a Symptoms of Lower Urinary Tract Dysfunction Research Network Cross-Sectional Case-Control Study. J Urol 2024:101097JU0000000000004022. [PMID: 38717915 DOI: 10.1097/ju.0000000000004022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Our objective was to investigate structural changes in brain white matter tracts using diffusion tensor imaging (DTI) in patients with overactive bladder (OAB). MATERIALS AND METHODS Treatment-seeking OAB patients and matched controls enrolled in the cross-sectional case-control LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) Neuroimaging Study received a brain DTI scan. Microstructural integrity of brain white matter was assessed using fractional anisotropy (FA) and mean diffusivity. OAB and urgency urinary incontinence (UUI) symptoms were assessed using the OAB Questionnaire Short-Form and International Consultation on Incontinence Questionnaire-Urinary Incontinence. The Lower Urinary Tract Symptoms Tool UUI questions and responses were correlated with FA values. RESULTS Among 221 participants with evaluable DTI data, 146 had OAB (66 urinary urgency-only without UUI, 80 with UUI); 75 were controls. Compared with controls, participants with OAB showed decreased FA and increased mean diffusivity, representing greater microstructural abnormalities of brain white matter tracts among OAB participants. These abnormalities occurred in the corpus callosum, bilateral anterior thalamic radiation and superior longitudinal fasciculus tracts, and bilateral insula and parahippocampal region. Among participants with OAB, higher OAB Questionnaire Short-Form scores were associated with decreased FA in the left inferior fronto-occipital fasciculus, P < .0001. DTI differences between OAB and controls were driven by the urinary urgency-only (OAB-dry) but not the UUI (OAB-wet) subgroup. CONCLUSIONS Abnormalities in microstructural integrity in specific brain white matter tracts were more frequent in OAB patients. More severe OAB symptoms were correlated with greater degree of microstructural abnormalities in brain white matter tracts in patients with OAB.
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Affiliation(s)
- H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jerrel Rutlin
- Departments of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - James A Hokanson
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, Washington
| | | | | | - C Emi Bretschneider
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Kimberly Kenton
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Karen John
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Joshua S Shimony
- Departments of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
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Sutcliffe S, Falke C, Fok CS, Griffith JW, Harlow BL, Kenton KA, Lewis CE, Low LK, Lowder JL, Lukacz ES, Markland AD, McGwin G, Meister MR, Mueller ER, Newman DK, Pakpahan R, Rickey LM, Rockwood T, Simon MA, Smith AR, Rudser KD, Smith AL. Lower Urinary Tract Symptoms in US Women: Contemporary Prevalence Estimates from the RISE FOR HEALTH Study. J Urol 2024:101097JU0000000000004009. [PMID: 38703067 DOI: 10.1097/ju.0000000000004009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND To estimate the prevalence of a wide range of lower urinary tract symptoms (LUTS) in US women, and to explore associations with bother and discussion with healthcare providers, friends, and family. MATERIALS AND METHODS We analyzed baseline data collected from 5/2022-12/2023 in the RISE FOR HEALTH study-a large, regionally-representative cohort study of adult female community members. LUTS and related bother were measured by the 10-item Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index and discussion was assessed by a study-specific item. RESULTS Of the 3000 eligible participants, 73% (95% confidence interval [CI] = 71-74%) reported any storage symptoms, 52% (95% CI = 50-53) any voiding or emptying symptoms, and 11% (95% CI = 10-13%) any pain with bladder filling, for an overall LUTS prevalence of 79% (95% CI = 78-81%). This prevalence estimate included 43% (95% CI = 41-45%) of participants with mild-to-moderate symptoms and 37% (95% CI = 35-38%) with moderate-to-severe symptoms. Over one-third of participants reported LUTS-related bother (38%, 95% CI = 36-39%) and discussion (38%, 95% CI = 36-40%), whereas only 7.1% (95% CI = 6.2-8.1%) reported treatment. Urgency and incontinence (including urgency and stress incontinence) were associated with the greatest likelihood of bother and/or discussion (adjusted prevalence ratios = 1.3-2.3), even at mild-to-moderate levels. They were also the most commonly treated LUTS. CONCLUSIONS LUTS, particularly storage LUTS such as urgency and incontinence, were common and bothersome in the RISE study population, yet often untreated. Given this large burden, both prevention and treatment-related interventions are warranted to reduce the high prevalence and bother of LUTS.
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Affiliation(s)
- Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Chloe Falke
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, Minnesota
| | - Cynthia S Fok
- Department of Urology and the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - James W Griffith
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Bernard L Harlow
- Boston University School of Public Health, Boston, Massachusetts
| | - Kimberly A Kenton
- Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Emily S Lukacz
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, California
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, and the Geriatric Research, Education, and Clinical Center at the Birmingham Veterans Affairs Health Care System, Birmingham, Alabama
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melanie R Meister
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas
| | - Elizabeth R Mueller
- Departments of Obstetrics and Gynecology, and Urology, Loyola University Medical Center, Loyola University Chicago, Chicago, Illinois
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ratna Pakpahan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Leslie M Rickey
- Department of Urology and the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Todd Rockwood
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Melissa A Simon
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Abigail R Smith
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kyle D Rudser
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, Minnesota
| | - Ariana L Smith
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Smith AR, Mansfield SA, Bradley CS, Kenton KS, Helmuth ME, Cameron AP, Kirkali Z, Emi Bretschneider C, Andreev V, Sarma A, Lane G, Collins SA, Cella D, Henry Lai H, Harte SE, Griffith JW. Relationships Between Urinary and Nonurinary Symptoms in Treatment-Seeking Women in LURN. Urogynecology (Phila) 2024; 30:123-131. [PMID: 37428882 PMCID: PMC10751379 DOI: 10.1097/spv.0000000000001388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
IMPORTANCE Physical health and psychological health represent modifiable factors in the causal pathway of lower urinary tract symptoms (LUTS). OBJECTIVES Understand the relationship between physical and psychological factors and LUTS over time. STUDY DESIGN Adult women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study completed the LUTS Tool and Pelvic Floor Distress Inventory, including urinary (Urinary Distress Inventory), prolapse (Pelvic Organ Prolapse Distress Inventory), and colorectal anal (Colorectal-Anal Distress Inventory) subscales at baseline, 3 months, and 12 months. Physical functioning, depression, and sleep disturbance were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires; relationships were assessed using multivariable linear mixed models. RESULTS Of 545 women enrolled, 472 had follow-up. Median age was 57 years; 61% and 78% reported stress urinary incontinence and overactive bladder, respectively; and 81% reported obstructive symptoms. The PROMIS depression scores were positively associated with all urinary outcomes (range, 2.5- to 4.8-unit increase per 10-unit increase in depression score; P < 0.01 for all). Higher sleep disturbance scores were associated with higher urgency, obstruction, LUTS Total Severity, Urinary Distress Inventory, and Pelvic Floor Distress Inventory (1.9- to 3.4-point increase per 10-unit increase, all P < 0.02). Better physical functioning was associated with less severe urinary symptoms except stress urinary incontinence (2.3- to 5.2-point decrease per 10-unit increase, all P < 0.01). All symptoms decreased over time; however, no association was detected between baseline PROMIS scores and trajectories of LUTS over time. CONCLUSIONS Nonurologic factors demonstrated small to medium cross-sectional associations with urinary symptom domains, but no significant association was detected with changes in LUTS. Further work is needed to determine whether interventions targeting nonurologic factors reduce LUTS in women.
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Affiliation(s)
| | | | | | | | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | | | | | | | - Sarah A. Collins
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - David Cella
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - H. Henry Lai
- Washington University in St. Louis, St. Louis, MO
| | - Steven E. Harte
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI
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Mawla I, Schrepf A, Kutch JJ, Helmuth ME, Smith AR, Ichesco E, Yang CC, Andreev VP, Kreder KJ, Bradley CS, Magnotta VA, Kirkali Z, Harris RE, Lai HH, Harte SE. Reply By Authors. J Urol 2024; 211:122-123. [PMID: 37796787 DOI: 10.1097/ju.0000000000003699.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/01/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Ishtiaq Mawla
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Eric Ichesco
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, Washington
| | | | - Karl J Kreder
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Catherine S Bradley
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Richard E Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
- Susan Samueli Integrative Health Institute, School of Medicine, University of California at Irvine, Irvine, California
| | - H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Steven E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Wang CS, Glenn DA, Helmuth M, Smith AR, Bomback AS, Canetta PA, Coppock GM, Khalid M, Tuttle KR, Bou-Matar R, Greenbaum LA, Robinson BM, Holzman LB, Smoyer WE, Rheault MN, Gipson D, Mariani LH. Association of COVID-19 Versus COVID-19 Vaccination With Kidney Function and Disease Activity in Primary Glomerular Disease: A Report of the Cure Glomerulonephropathy Study. Am J Kidney Dis 2024; 83:37-46. [PMID: 37657635 PMCID: PMC10841160 DOI: 10.1053/j.ajkd.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 09/03/2023]
Abstract
RATIONALE & OBJECTIVE Patients with glomerular disease (GN) may be at increased risk of severe COVID-19, yet concerns over vaccines causing disease relapse may lead to vaccine hesitancy. We examined the associations of COVID-19 with longitudinal kidney function and proteinuria and compared these with similar associations with COVID-19 vaccination. STUDY DESIGN Observational cohort study from July 1, 2021, to January 1, 2023. SETTING & PARTICIPANTS A prospective observational study network of 71 centers from North America and Europe (CureGN) with children and adults with primary minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy. EXPOSURE COVID-19 and COVID-19 vaccination. OUTCOME Repeated measure of estimated glomerular filtration rate (eGFR); recurrent time-to-event outcome of GN disease worsening as defined by doubling of the urinary protein-creatinine ratio (UPCR) to at least 1.5g/g or increase in dipstick urine protein by 2 ordinal levels to 3+(300mg/dL) or above. ANALYTICAL APPROACH Interrupted time series analysis for eGFR. Prognostic matched sequential stratification recurrent event analysis for GN disease worsening. RESULTS Among 2,055 participants, 722 (35%) reported COVID-19 infection; of these, 92 (13%) were hospitalized, and 3 died (<1%). The eGFR slope before COVID-19 infection was-1.40mL/min/1.73m2 (± 0.29 SD); within 6 months after COVID-19 infection, the eGFR slope was-4.26mL/min/1.73m2 (± 3.02 SD), which was not significantly different (P=0.34). COVID-19 was associated with increased risk of worsening GN disease activity (HR, 1.35 [95% CI, 1.01-1.80]). Vaccination was not associated with a change in eGFR (-1.34mL/min/1.73m2±0.15 SD vs-2.16mL/min/1.73m2±1.74 SD; P=0.6) or subsequent GN disease worsening (HR 1.02 [95% CI, 0.79-1.33]) in this cohort. LIMITATIONS Infrequent or short follow-up. CONCLUSIONS Among patients with primary GN, COVID-19 infection was severe for 1 in 8 cases and was associated with subsequent worsening of GN disease activity, as defined by proteinuria. By contrast, vaccination against COVID-19 was not associated with change in disease activity or kidney function decline. These results support COVID-19 vaccination for patients with GN. PLAIN-LANGUAGE SUMMARY In this cohort study of 2,055 patients with minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy, COVID-19 resulted in hospitalization or death for 1 in 8 cases and was associated with a 35% increase in risk for worsening proteinuria. By contrast, vaccination did not appear to adversely affect kidney function or proteinuria. Our data support vaccination for COVID-19 in patients with glomerular disease.
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Affiliation(s)
- Chia-Shi Wang
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Dorey A Glenn
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | | | - Myda Khalid
- Riley Hospital for Children, School of Medicine, Indiana University, Indianapolis, Indiana
| | | | - Raed Bou-Matar
- Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - William E Smoyer
- Research Institute at Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio
| | - Michelle N Rheault
- Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Mawla I, Schrepf A, Kutch JJ, Helmuth ME, Smith AR, Ichesco E, Yang CC, Andreev VP, Kreder KJ, Bradley CS, Magnotta VA, Kirkali Z, Harris RE, Lai HH, Harte SE. Naturalistic Bladder Filling Reveals Subtypes in Overactive Bladder Syndrome That Differentially Engages Urinary Urgency-Related Brain Circuits: Results From the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). J Urol 2024; 211:111-123. [PMID: 37796776 DOI: 10.1097/ju.0000000000003699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/01/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE Overactive bladder (OAB) may be attributed to dysfunction in supraspinal brain circuits. Overactive bladder participants enrolled in the LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) study reported sensations of urinary urgency during a bladder-filling paradigm while undergoing brain functional MRI to map supraspinal dysfunction. MATERIALS AND METHODS OAB participants and controls (CONs) completed 2 resting-state functional MRI scans following consumption of 350 mL water. Scans were conducted at fuller and emptier bladder states, interleaved with voiding. Urgency ratings (0-10) were assessed. Patterns of urgency during bladder filling were investigated using latent class trajectory models. Clusters of participants encompassing each pattern (ie, subtype) were derived from aggregated groups of OAB and CON independent of diagnosis. RESULTS Two distinct patterns of urgency trajectories were revealed: first subtype with OAB and CON who were unresponsive to bladder filling (OAB-1 and CON-1) and second highly responsive subtype predominantly containing OAB (OAB-2). OAB-2 participants scored significantly higher on urinary symptoms but not pain or psychosocial measures. Neuroimaging analyses showed change in urgency due to both bladder filling and voided volume related to multiple loci of brain network connectivity in OAB-2, and in some cases, different than OAB-1 and/or CON-1. Sensorimotor to dorsomedial/dorsolateral prefrontal connectivity mediated the relationship between stimulus (voided volume) and percept (urgency) in OAB-2. CONCLUSIONS Our results reveal different OAB subtypes with latent class trajectory models of urgency ratings during natural bladder filling. Functional MRI revealed differences in pathophysiology between subtypes, namely sensorimotor-prefrontal connectivity is a key locus in OAB patients with higher urinary symptoms.
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Affiliation(s)
- Ishtiaq Mawla
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Eric Ichesco
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, Washington
| | | | - Karl J Kreder
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Catherine S Bradley
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Richard E Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
- Susan Samueli Integrative Health Institute, School of Medicine, University of California at Irvine, Irvine, California
| | - H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Steven E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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7
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Andreev VP, Helmuth ME, Smith AR, Zisman A, Cameron AP, DeLancey JOL, Bushman WA. Dynamic analysis of the individual patterns of intakes, voids, and bladder sensations reported in bladder diaries collected in the LURN study. PLoS One 2023; 18:e0284544. [PMID: 37983243 PMCID: PMC10659201 DOI: 10.1371/journal.pone.0284544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023] Open
Abstract
The goal of this study was to develop the novel analytical approach and to perform an in-depth dynamic analysis of individual bladder diaries to inform which behavioral modifications would best reduce lower urinary tract symptoms, such as frequency and urgency. Three-day bladder diaries containing data on timing, volumes, and types of fluid intake, as well as timing, volumes, and bladder sensation at voids were analyzed for 197 participants with lower urinary tract symptoms. A novel dynamic analytic approach to bladder diary time series data was proposed and developed, including intra-subject correlations between time-varying variables: rates of intake, bladder filling rate, and urge growth rate. Grey-box models of bladder filling rate and multivariable linear regression models of urge growth rate were developed for individual diaries. These models revealed that bladder filling rate, rather than urine volume, was the primary determinant of urinary frequency and urgency growth rate in the majority of participants. Simulations performed with the developed models predicted that the most beneficial behavioral modifications to reduce the number of urgency episodes are those that smooth profiles of bladder filling rate, which might include behaviors such as exclusion of caffeine and alcohol and/or other measures, e.g., increasing number and decreasing volumes of intakes.
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Affiliation(s)
- Victor P. Andreev
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States of America
| | - Margaret E. Helmuth
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States of America
| | - Abigail R. Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States of America
| | - Anna Zisman
- Section of Nephrology, University of Chicago, Chicago, IL, United States of America
| | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, MI, United States of America
| | - John O. L. DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Wade A. Bushman
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
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8
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Bretschneider CE, Liu Q, Smith AR, Mansfield SA, Kirkali Z, Amundsen CL, Lai HH, Geynisman-Tan J, Kirby A, Jelovsek JE. Development and validation of models predicting treatment patterns in women with urinary urgency and/or urgency incontinence: A Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study. Neurourol Urodyn 2023; 42:1214-1226. [PMID: 37269483 PMCID: PMC10581676 DOI: 10.1002/nau.25222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE To develop a tool to predict a woman's treatment pattern for bothersome urinary urgency (UU) and/or UU incontinence over 1 year after presenting for care at urology or urogynecology clinics. METHODS The Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study enrolled adult women with bothersome UU and/or UU incontinence using the lower urinary tract symptoms (LUTS) Tool who were seeking care for LUTS. Treatments for UU and/or urgency incontinence were ordered from least to most invasive. Ordinal logistic and Cox proportional hazard regression models were fit to predict the most invasive level of treatment during follow-up and overactive bladder (OAB) medication discontinuation, respectively. Binary logistic regression was performed to predict sling treatment during the study follow-up. Clinical tools were then created using the models listed above to predict treatment pattern over 12 months. RESULTS Among 349 women, 281 reported UU incontinence, and 68 reported UU at baseline. The highest level of treatment during the study was as follows: 20% no treatment, 24% behavioral treatments, 23% physical therapy, 26% OAB medication, 1% percutaneous tibial nerve stimulation, 3% onabotulinumtoxin A, and 3% sacral neuromodulation. Slings were placed in 10% (n = 36) of participants before baseline and in 11% (n = 40) during study follow-up. Baseline factors associated with predicting the most invasive level of treatment included baseline level of treatment, hypertension, UU incontinence severity, stress urinary incontinence (SUI) severity, and anticholinergic burden score. Less severe baseline depression and less severe UU incontinence were associated with OAB medication discontinuation. UU and SUI severity were associated with sling placement during the study period. Three tools are available to predict: (1) highest level of treatment; (2) OAB medication discontinuation; and (3) sling placement. CONCLUSIONS OAB treatment prediction tools developed in this study can help providers individualize treatment plans and identify not only patients at risk for treatment discontinuation but also patients who may not be escalated to potentially beneficial OAB treatments, with the goal to improve clinical outcomes for patients suffering from this chronic and often debilitating condition.
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Affiliation(s)
- C. Emi Bretschneider
- Northwestern University; Urogynecology and Reconstructive Surgery; Chicago IL, US
| | - Qian Liu
- Arbor Research Collaborative for Health; Ann Arbor MI, US
| | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); Division of Kidney, Urologic, & Hematologic Diseases; Bethesda MD, US
| | - Cindy L. Amundsen
- Duke University; Department of Obstetrics and Gynecology, Division of Urogynecology; Durham NC, US
| | - H. Henry Lai
- Washington University in St. Louis; Division of Urologic Surgery, Departments of Surgery and Anesthesiology; St. Louis MO, US
| | - Julia Geynisman-Tan
- Northwestern University; Urogynecology and Reconstructive Surgery; Chicago IL, US
| | - Anna Kirby
- University of Washington; Obstetrics, Gynecology, & Pelvic Medicine; Seattle WA, US
| | - J. Eric Jelovsek
- Duke University; Department of Obstetrics and Gynecology, Division of Urogynecology; Durham NC, US
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9
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Andreev VP, Helmuth ME, Smith AR, Zisman A, Cameron AP, DeLancey JOL, Bushman WA. Dynamic analysis of the individual patterns of intakes, voids, and bladder sensations reported in bladder diaries collected in the LURN study. medRxiv 2023:2023.04.05.23288100. [PMID: 37066258 PMCID: PMC10104230 DOI: 10.1101/2023.04.05.23288100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
The goal of this study was to perform an in-depth dynamic analysis of individual bladder diaries to inform which behavioral modifications would best reduce lower urinary tract symptoms, such as frequency and urgency. Three-day bladder diaries containing data on timing, volumes, and types of fluid intake, as well as timing, volumes, and bladder sensation at voids were analyzed for 197 participants with lower urinary tract symptoms. A novel dynamic analytic approach to bladder diary time series data was proposed and developed, including intra-subject correlations between time-varying variables: rates of intake, bladder filling rate, and urge growth rate. Grey-box models of bladder filling rate and multivariable linear regression models of urge growth rate were developed for individual diaries. These models revealed that bladder filling rate, rather than urine volume, was the primary determinant of urinary frequency and urgency growth rate in the majority of participants. Simulations performed with the developed models predicted that the most beneficial behavioral modifications to reduce the number of urgency episodes are those that smooth profiles of bladder filling rate, which might include behaviors such as exclusion of caffeine and alcohol and/or other measures, e.g., increasing number and decreasing volumes of intakes.
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Affiliation(s)
| | | | | | - Anna Zisman
- Section of Nephrology, University of Chicago, Chicago IL, US
| | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor MI, US
| | - John O. L. DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor MI, US
| | - Wade A. Bushman
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison WI, US
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10
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Krissberg JR, O'Shaughnessy MM, Smith AR, Helmuth ME, Almaani S, Aviles DH, Brathwaite KE, Cai Y, Cattran D, Gbadegesin R, Glenn DA, Greenbaum LA, Iragorri S, Jain K, Khalid M, Kidd J, Kopp J, Lafayette R, Lane JC, Lugani F, Nestor JG, Parekh RS, Reidy K, Selewski DT, Sethna CB, Sperati CJ, Tuttle K, Twombley K, Vasylyeva TL, Weaver DJ, Wenderfer SE, Gibson K. Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease. Am J Kidney Dis 2023; 81:318-328.e1. [PMID: 36191724 PMCID: PMC9974571 DOI: 10.1053/j.ajkd.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE & OBJECTIVE The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort. EXPOSURE Race and ethnicity as a participant-reported social factor. OUTCOME Acute care utilization defined as hospitalizations or emergency department visits. ANALYTICAL APPROACH Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization. RESULTS Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified. LIMITATIONS We used proxies for SES and lacked direct information on income, household unemployment, or disability. CONCLUSIONS Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.
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Affiliation(s)
- Jill R Krissberg
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Michelle M O'Shaughnessy
- Department of Renal Medicine, Cork University Hospital, Ireland; and School of Medicine, University College Cork, Ireland
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Diego H Aviles
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Kaye E Brathwaite
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - Yi Cai
- Pediatric Nephrology, Dialysis and Transplantation, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Daniel Cattran
- Division of Nephrology, University Health Network, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Myda Khalid
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Richard Lafayette
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Jerome C Lane
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Francesca Lugani
- L'Unità Operativa Complessa Nefrology, Dialysis and Transplant, Laboratorio di Nefrologia Molecolare, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Jordan G Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Rulan S Parekh
- Division of Nephrology, Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kimberly Reidy
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - David T Selewski
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Christine B Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York
| | - C John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Tuttle
- Providence Health Care, Department of Medicine, Division of Nephrology, University of Washington, Spokane and Seattle, Washington
| | - Katherine Twombley
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Tetyana L Vasylyeva
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's, Charlotte, North Carolina
| | - Scott E Wenderfer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Keisha Gibson
- Department of Medicine and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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11
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Wang L, Smith-Salzberg B, Meyers KE, Glenn DA, Tuttle KR, Derebail VK, Brady TM, Gibson K, Smith AR, O'Shaughnessy MM, Srivastava T, Hall G, Zee J, Bitzer M, Sethna CB. Tobacco exposure in adults and children with proteinuric glomerulopathies: a NEPTUNE cohort study. BMC Nephrol 2023; 24:30. [PMID: 36759756 PMCID: PMC9912673 DOI: 10.1186/s12882-023-03073-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Tobacco exposure has been recognized as a risk factor for cardiovascular disease (CVD) and progression of kidney disease. Patients with proteinuric glomerulopathies are at increased risk for cardiovascular morbidity and mortality. Multiple studies have linked tobacco exposure to CVD and chronic kidney disease, but the relationships between smoking and proteinuric glomerulopathies in adults and children have not been previously explored. METHODS Data from the Nephrotic Syndrome Study Network (NEPTUNE), a multi-center prospective observational study of participants with proteinuric glomerulopathies, was analyzed. 371 adults and 192 children enrolled in NEPTUNE were included in the analysis. Self-reported tobacco exposure was classified as non-smoker, active smoker, former smoker, or exclusive passive smoker. Baseline serum cotinine levels were measured in a sub-cohort of 178 participants. RESULTS The prevalence of active smokers, former smokers and exclusive passive smoking among adults at baseline was 14.6%, 29.1% and 4.9%, respectively. Passive smoke exposure was 16.7% among children. Active smoking (reference non-smoking) was significantly associated with greater total cholesterol among adults (β 17.91 95% CI 0.06, 35.76, p = 0.049) while passive smoking (reference non-smoking) was significantly associated with greater proteinuria over time among children (β 1.23 95% CI 0.13, 2.33, p = 0.03). Higher cotinine levels were associated with higher baseline eGFR (r = 0.17, p = 0.03). CONCLUSION Tobacco exposure is associated with greater risk for CVD and worse kidney disease outcomes in adults and children with proteinuric glomerulopathies. Preventive strategies to reduce tobacco exposure may help protect against future cardiovascular and kidney morbidity and mortality in patients with proteinuric glomerulopathies.
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Affiliation(s)
- Linda Wang
- Cohen Children's Medical Center of NY, New Hyde Park, NY, USA
| | | | | | - Dorey A Glenn
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, USA
- Nephrology Division and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Vimal K Derebail
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Keisha Gibson
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Gentzon Hall
- Division of Nephrology, Duke University School of Medicine, 269-01 76th Avenue, 11040, Durham, NC, USA
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Christine B Sethna
- Cohen Children's Medical Center of NY, New Hyde Park, NY, USA.
- Division of Nephrology, Duke University School of Medicine, 269-01 76th Avenue, 11040, Durham, NC, USA.
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12
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Chen DP, Helmuth ME, Smith AR, Canetta PA, Ayoub I, Mucha K, Kallash M, Kopp JB, Gbadegesin R, Gillespie BW, Greenbaum LA, Parekh RS, Hunley TE, Sperati CJ, Selewski DT, Kidd J, Chishti A, Reidy K, Mottl AK, Gipson DS, Srivastava T, Twombley KE. Age of Onset and Disease Course in Biopsy-Proven Minimal Change Disease: An Analysis From the Cure Glomerulonephropathy Network. Am J Kidney Dis 2023; 81:695-706.e1. [PMID: 36608921 DOI: 10.1053/j.ajkd.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/19/2022] [Indexed: 01/05/2023]
Abstract
RATIONALE & OBJECTIVE Adolescent- and adult-onset minimal change disease (MCD) may have a clinical course distinct from childhood-onset disease. We characterized the course of children and adults with MCD in the Cure Glomerulonephropathy Network (CureGN) and assessed predictors of rituximab response. STUDY DESIGN Prospective, multicenter, observational study. STUDY PARTICIPANTS CureGN participants with proven MCD on biopsy. EXPOSURE Age at disease onset, initiation of renin-angiotensin-aldosterone system (RAAS) blockade, and immunosuppression including rituximab during the study period. OUTCOME Relapse and remission, change in estimated glomerular filtration rate (eGFR), and kidney failure. ANALYTICAL APPROACH Remission and relapse probabilities were estimated using Kaplan-Meier curves and gap time recurrent event models. Linear regression models were used for the outcome of change in eGFR. Cox proportional hazards models were used to estimate the association between rituximab administration and remission. RESULTS The study included 304 childhood- (≤12 years old), 49 adolescent- (13-17 years old), and 201 adult- (≥18 years) onset participants with 2.7-3.2 years of follow-up after enrollment. Children had a longer time to biopsy (238 vs 23 and 36 days in adolescent- and adult-onset participants, respectively; P<0.001) and were more likely to have received therapy before biopsy. Children were more likely to be treated with immunosuppression but not RAAS blockade. The rate of relapse was higher in childhood- versus adult-onset participants (HR, 1.69 [95% CI, 1.29-2.21]). The probability of remission was also higher in childhood-onset disease (HR, 1.33 [95%CI, 1.02-1.72]). In all groups eGFR loss was minimal. Children were more likely to remit after rituximab than those with adolescent- or adult-onset disease (adjusted HR, 2.1; P=0.003). Across all groups, glucocorticoid sensitivity was associated with a greater likelihood of achieving complete remission after rituximab (adjusted HR, 2.62; P=0.002). LIMITATIONS CureGN was limited to biopsy-proven disease. Comparisons of childhood to nonchildhood cases of MCD may be subject to selection bias, given that childhood cases who undergo a biopsy may be limited to patients who are least responsive to initial therapy. CONCLUSIONS Among patients with MCD who underwent kidney biopsy, there were differences in the course (relapse and remission) of childhood-onset compared with adolescent- and adult-onset disease, as well as rituximab response.
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Affiliation(s)
- Dhruti P Chen
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina.
| | - Margaret E Helmuth
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Isabelle Ayoub
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Krzysztof Mucha
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Mahmoud Kallash
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio; Division of Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey B Kopp
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Baltimore, Maryland
| | - Rasheed Gbadegesin
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Brenda W Gillespie
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Rulan S Parekh
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - David T Selewski
- Medical University of South Carolina, Charleston, South Carolina
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Kimberly Reidy
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Amy K Mottl
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Debbie S Gipson
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
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13
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Bretschneider CE, Liu Q, Smith AR, Kirkali Z, Amundsen CL, Lai HH, Geynisman-Tan J, Kirby A, Cameron AP, Helmuth ME, Griffith JW, Jelovsek JE. Treatment patterns in women with urinary urgency and/or urgency urinary incontinence in the symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study. Neurourol Urodyn 2023; 42:194-204. [PMID: 36579974 PMCID: PMC9811511 DOI: 10.1002/nau.25067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited epidemiological data exist describing how patients engage with various treatments for overactive bladder (OAB). To improve care for patients with OAB, it is essential to gain a better understanding of how patients interface with OAB treatments longitudinally, that is, how often patients change treatments and the pattern of this treatment change in terms of escalation and de-escalation. OBJECTIVES To describe treatment patterns for women with bothersome urinary urgency (UU) and/or urgency urinary incontinence (UUI) presenting to specialty care over 1 year. STUDY DESIGN The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) study enrolled adult women with bothersome UU and/or UUI seeking care for lower urinary tract symptoms (LUTS) between January 2015 and September 2016. An ordinal logistic regression model was fitted to describe the probabilities of escalating or de-escalating level of treatment during 1-year follow-up. RESULTS Among 349 women, 281 reported UUI and 68 reported UU at baseline. At the end of 1 year of treatment by a urologist or urogynecologist, the highest level of treatment received by participants was 5% expectant management, 36% behavioral treatments (BT), 26% physical therapy (PT), 26% OAB medications, 1% percutaneous tibial nerve stimulation, 3% intradetrusor onabotulinum toxin A injection, and 3% sacral neuromodulation. Participants using BT or PT at baseline were more likely to be de-escalated to no treatment than participants on OAB medications at baseline, who tended to stay on medications. Predictors of the highest level of treatment included starting level of treatment, hypertension, UUI severity, stress urinary incontinence, and anticholinergic burden score. CONCLUSIONS Treatment patterns for UU and UUI are diverse. Even for patients with significant bother from OAB presenting to specialty clinics, further treatment often only involves conservative or medical therapies. This study highlights the need for improved treatment algorithms to escalate patients with persistent symptoms, or to adjust care in those who have been unsuccessfully treated.
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Affiliation(s)
| | - Q. Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD USA
| | | | - H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Anna Kirby
- University of Washington Medical Center, Seattle, WA, USA
| | | | | | - James W. Griffith
- Northwestern University – The Feinberg School of Medicine, Chicago, IL, USA
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14
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Lai HH, Wiseman JB, Helmuth ME, Smith AR, Amundsen CL, Cameron AP, Glaser AP, Hendrickson WK, Kirkali Z, Kenton K. Phenotyping of Urinary Urgency Patients Without Urgency Incontinence, and Their Comparison to Urgency Incontinence Patients: Findings From the LURN Study. J Urol 2023; 209:233-242. [PMID: 36067368 PMCID: PMC9742334 DOI: 10.1097/ju.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE We characterize patients with urinary urgency with vs without urgency urinary incontinence who presented to clinics actively seeking treatment for their symptoms. MATERIALS AND METHODS Participants who enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network were categorized into urinary urgency with vs without urgency urinary incontinence. Participants were followed for 1 year; their urinary symptoms, urological pain, psychosocial factors, bowel function, sleep disturbance, physical activity levels, physical function, and quality of life were compared. Mixed effects linear regression models were used to examine the relationships between urgency urinary incontinence and these factors. RESULTS Among 683 participants with urinary urgency at baseline, two-thirds (n=453) also had urgency urinary incontinence; one-third (n=230) had urinary urgency-only without urgency urinary incontinence. No differences were detected in urological pain between urinary urgency-only and urgency urinary incontinence. Those with urgency urinary incontinence had more severe urgency and frequency symptoms, higher depression, anxiety, perceived stress scores, more severe bowel dysfunction and sleep disturbance, lower physical activity levels, lower physical function, and worse quality of life than those with urinary urgency-only. Among those with urinary urgency-only at baseline, 40% continued to have urinary urgency-only, 15% progressed to urgency urinary incontinence, and 45% had no urgency at 12 months. Fifty-eight percent with urgency urinary incontinence at baseline continued to report urgency urinary incontinence at 12 months, while 15% improved to urinary urgency-only, and 27% had no urgency. CONCLUSIONS Patients with urgency urinary incontinence have severe storage symptoms, more psychosocial symptoms, poorer physical functioning, and worse quality of life. Our data suggested urgency urinary incontinence may be a more severe manifestation of urinary urgency, rather than urinary urgency and urgency urinary incontinence being distinct entities.
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Affiliation(s)
- H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis MO
| | | | | | | | - Cindy L. Amundsen
- Department of Obstetrics and Gynecology, Division of Urogynecology, Duke University, Durham NC
| | | | | | - Whitney K. Hendrickson
- Department of Obstetrics and Gynecology, Division of Urogynecology, Duke University, Durham NC
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda MD
| | - Kimberly Kenton
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Northwestern University, Chicago IL
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15
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Palmer MB, Royal V, Jennette JC, Smith AR, Liu Q, Ambruzs JM, Andeen NK, D'Agati VD, Fogo AB, Gaut J, Gbadegesin RA, Greenbaum LA, Hou J, Helmuth ME, Lafayette RA, Liapis H, Robinson B, Stokes MB, Twombley K, Yin H, Nast CC. Cure Glomerulonephropathy Pathology Classification and Core Scoring Criteria, Reproducibility, and Clinicopathologic Correlations. Glomerular Dis 2023; 3:248-257. [PMID: 38021464 PMCID: PMC10665033 DOI: 10.1159/000534755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Introduction Cure Glomerulonephropathy (CureGN) is an observational cohort study of patients with minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), or IgA nephropathy. We developed a conventional, consensus-based scoring system to document pathologic features for application across multiple pathologists and herein describe the protocol, reproducibility, and correlation with clinical parameters at biopsy. Methods Definitions were established for glomerular, tubular, interstitial, and vascular lesions evaluated semiquantitatively using digitized light microscopy slides and electron micrographs, and reported immunofluorescence. Cases with curated pathology materials as of April 2019 were scored by a randomly assigned pathologist, with at least 10% of cases scored by a second pathologist. Scoring reproducibility was assessed using Gwet's agreement coefficient (AC)1 statistic and correlations with clinical variables were performed. Results Of 800 scored biopsies (134 MCD, 194 FSGS, 206 MN, 266 IgA), 94 were scored twice (11.8%). Of 60 pathology features, 46 (76.7%) demonstrated excellent (AC1>0.8), and 12 (20.0%) had good (AC1 0.6-0.8) reproducibility. Mesangial hypercellularity scored as absent, focal, or diffuse had moderate reproducibility (AC1 = 0.58), but good reproducibility (AC1 = 0.71) when scored as absent or focal versus diffuse. The percent glomeruli scored as no lesions had fair reproducibility (AC1 = 0.34). Strongest correlations between pathologic features and clinical characteristics at biopsy included interstitial inflammation, interstitial fibrosis, and tubular atrophy with estimated glomerular filtration rate, foot process effacement with urine protein/creatinine ratio, and active crescents with hematuria. Conclusions Most scored pathology features showed excellent reproducibility, demonstrating consistency for these features across multiple pathologists. Correlations between certain pathologic features and expected clinical characteristics show the value of this approach for future studies on clinicopathologic correlations and biomarker discovery.
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Affiliation(s)
- Matthew B Palmer
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, USA
| | - Virginie Royal
- Department of Pathology, Hospital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada
| | - J Charles Jennette
- Department of Pathology, University of North Carolina Kidney Center, Chapel Hill, NC, USA
| | | | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Nicole K Andeen
- Department of Pathology, Oregon Health and Science University, Portland, OR, USA
| | | | - Agnes B Fogo
- Department of Pathology, Vanderbilt University, Nashville, TN, USA
| | - Joseph Gaut
- Department of Pathology, Washington University, St. Louis, MO, USA
| | - Rasheed A Gbadegesin
- Division of Nephrology, Duke Children's Hospital Medical Center, Durham, NC, USA
| | - Larry A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Jean Hou
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Richard A Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Helen Liapis
- Nephrology Center, Ludwig Maximilian University, Munich, Germany
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Katherine Twombley
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Hong Yin
- Pathology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Glaser AP, Kristof TW, Judge C, Javitch G, Hirsch S, Talaty P, Helfand BT, Smith AR, Griffith JW. The 10-item LURN Symptom Index (LURN SI-10) Detects Additional Symptoms and Shows Convergent Validity With the IPSS in Men Presenting With Lower Urinary Tract Symptoms. Urology 2023; 171:184-189. [PMID: 36370771 DOI: 10.1016/j.urology.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine how the LURN-SI-10, a novel questionnaire developed by the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), compares with the International Prostate Symptom Score (IPSS) in men with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). Specifically, to assess convergent validity and determine how frequently the LURN-SI-10 identifies symptoms not captured by the IPSS. MATERIALS AND METHODS Men presenting with BPH/LUTS were prospectively administered LURN-SI-10 and IPSS questionnaires. Urinary incontinence (UI) including post-void dribbling (PVD), urgency urinary incontinence (UUI), stress urinary incontinence (SUI), as well as bladder pain were considered present if the patient reported "about half the time or more" on LURN-SI-10. Correlations between LURN-SI-10 and IPSS were assessed as continuous and categorical variables. Multivariable linear regression analysis was performed to determine associations with symptom scores. RESULTS LURN-SI-10 and IPSS were highly correlated in men with BPH/LUTS (r = 0.82, n = 429), as were respective bother and quality of life scores (ρ = 0.74). The LURN-SI-10 identified additional symptoms including PVD (24%), UUI (13%), SUI (2%), and pain (8%). Men with any UUI, SUI, or PVD had on average a 7.6-point higher LURN-SI-10 score than those without UI (P<.001) and 8.0-point higher IPSS score than those without UI (P<.001). CONCLUSION The LURN-SI-10 correlates strongly with the IPSS, but the LURN-SI-10 identifies additional important symptomatology in men with LUTS. This additional information may improve the evaluation and treatment of men with BPH/LUTS. Further prospective studies of the LURN-SI-10 is warranted.
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Affiliation(s)
- Alexander P Glaser
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, IL.
| | - Tanya W Kristof
- Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Clark Judge
- Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - George Javitch
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, IL
| | - Shira Hirsch
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, IL
| | - Pooja Talaty
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, IL
| | - Brian T Helfand
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, IL
| | | | - James W Griffith
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Cameron AP, Helmuth ME, Smith AR, Lai HH, Amundsen CL, Kirkali Z, Gillespie BW, Yang CC, Clemens JQ. Total fluid intake, caffeine, and other bladder irritant avoidance among adults having urinary urgency with and without urgency incontinence: The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Neurourol Urodyn 2023; 42:213-220. [PMID: 36579975 PMCID: PMC9811496 DOI: 10.1002/nau.25070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/30/2022] [Accepted: 10/06/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Caffeine has long been vilified as a cause for urinary urgency incontinence (UUI) along with other potential bladder irritants such as carbonation, alcohol, and acidic juices. The objective of this study was to assess the fluid intake behavior of people with urgency, UUI, and those with lower urinary tract symptoms (LUTS) without UUI or urgency to assess if they avoided certain potential bladder irritants or had different fluid intake. We hypothesized that patients with UUI would avoid caffeine as a self-management method more so than these other two groups. METHODS Treatment-seeking men and women with LUTS in the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort study completed a baseline 3-day voiding and intake diary. "Complete" diaries had 3 days of data and no missing intake or voided volumes. Beverages with any caffeine, alcohol, carbonation, or acidic juice were identified and the total volume was recorded as well as the type of beverage containing caffeine to calculate the daily caffeine dose. RESULTS Four hundred and ninety-one participants (277 men and 214 women) with a median age of 63 had complete diaries. Urinary urgency was more prevalent in women than men (79% vs. 55%, p < 0.0001) as was UUI (84% vs. 47%, p < 0.0001). Total fluid intake over 3 days was lower among the urgency group versus the nonurgency group (median [interquartile range] 5.2 [4.0-6.8] L vs. 5.7 [4.3-7.0] L, p = 0.028) and the UUI group compared to the urgency without incontinence group were less likely to consume alcohol (26% vs. 37%, p = 0.04). After adjusting for sex, BMI, age, and total intake volume, UUI participants had 54% lower odds of consuming any caffeine (odds ratio = 0.46, 95% confidence interval = 0.22-0.96, p = 0.04) than those without incontinence, but among those that did consume caffeine, no difference in the volume of caffeinated beverages or milligrams of caffeine consumed was detected between those with UUI and those with urgency without incontinence. No difference in carbonation or acidic juice intake was detected between groups. CONCLUSIONS Individuals with urgency consume a lower volume of fluid than those without urgency. UUI participants more often abstain from caffeine, but among those that consume caffeine, the dose is similar to those without UUI. One explanation for these results is that only a subset of individuals with urgency or UUI are caffeine sensitive.
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Affiliation(s)
- Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Abigail R. Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - H. Henry Lai
- Departments of Surgery and Anesthesiology, Division of Urologic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Cindy L. Amundsen
- Department of Obsterics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | | | - Claire C. Yang
- Department of Urology, University of Washington, Seattle, Washington, USA
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Kowalski JT, Wiseman JB, Smith AR, Helmuth ME, Cameron A, DeLancey JOL, Hendrickson WK, Jelovsek JE, Kirby A, Kreder K, Lai HH, Mueller M, Siddiqui N, Bradley CS. Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Am J Obstet Gynecol 2022; 227:875.e1-875.e12. [PMID: 35934118 PMCID: PMC9729365 DOI: 10.1016/j.ajog.2022.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms. OBJECTIVE This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement. STUDY DESIGN Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not). RESULTS A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4). CONCLUSION Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.
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Affiliation(s)
- Joseph T Kowalski
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | | | | | | | | | | | - Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Anna Kirby
- University of Washington Medical Center, Seattle, WA
| | - Karl Kreder
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Margaret Mueller
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, and the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort Study Group
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19
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Flynn KE, Wiseman JB, Helmuth ME, Smith AR, Bradley CS, Cameron AP, Lai HH, Kirkali Z, Kreder KJ, Geynisman-Tan J, Merion RM, Weinfurt KP. Comparing clinical bladder diaries and recalled patient reports for measuring lower urinary tract symptoms in the symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Neurourol Urodyn 2022; 41:1711-1721. [PMID: 36066068 PMCID: PMC9633398 DOI: 10.1002/nau.25030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/06/2022] [Accepted: 08/05/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Bladder diaries are a key source of information about lower urinary tract symptoms (LUTS); however, many patients do not complete them as instructed. Questionnaire-based patient-reported outcome measures (PROMs) are another option for reporting LUTS but may have recall bias. We assessed the strength of the associations between PROMs and a 3-day bladder diary. MATERIALS AND METHODS Symptomatic adults from 6 tertiary care sites completed a 3-day paper bladder diary and 3-, 7-, and 30-day electronic PROMs. We assessed the linear associations between mapped pairs of diary variables and responses to PROM items using biserial and polyserial correlation coefficients with 95% confidence intervals. RESULTS Of 290 enrolled participants, 175 (60%) completed the bladder diary as instructed and at least one corresponding PROM. Linear associations were strongest between the diary and 3-day recall of daytime frequency (r = 0.75) and nighttime frequency (r = 0.69), followed by voids with urgency sensations (r = 0.62), and an item reporting any incontinence (r = 0.56). Linear associations between bladder diary and specific incontinence variables (e.g., stress, urgency) were low to negligible (ranging from r = 0.16-0.39). Linear associations were consistent across the 3-, 7-, and 30-day recall periods. CONCLUSIONS Missing and unusable bladder diary data were common, highlighting the patient burden associated with this method of data collection. A questionnaire-based PROM is a reasonable alternative to a diary for reporting voiding frequency and may offer an easier option for reporting some symptoms.
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Affiliation(s)
- Kathryn E. Flynn
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee WI
| | | | | | | | - Catherine S. Bradley
- Department of Obstetrics and Gynecology, University of Iowa, Carver College of Medicine, Iowa City IA
| | | | - H. Henry Lai
- Department of Surgery, Washington University in St Louis, St Louis MO
| | - Ziya Kirkali
- Division of Kidney, Urologic, and Hematologic Diseases; National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda MD
| | - Karl J. Kreder
- Department of Obstetrics and Gynecology, University of Iowa, Carver College of Medicine, Iowa City IA
| | | | | | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University Medical Center, Durham NC
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Glaser AP, Mansfield S, Smith AR, Helfand BT, Lai HH, Sarma A, Yang CC, Taddeo M, Clemens JQ, Cameron AP, Flynn KE, Andreev V, Fraser MO, Erickson BA, Kirkali Z, Griffith JW. Impact of Sleep Disturbance, Physical Function, Depression and Anxiety on Male Lower Urinary Tract Symptoms: Results from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). J Urol 2022; 208:155-163. [DOI: 10.1097/ju.0000000000002493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alexander P. Glaser
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, Illinois
| | - Sarah Mansfield
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Brian T. Helfand
- Department of Surgery, Division of Urology, NorthShore University HealthSystem, Evanston, Illinois
| | - H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
| | - Aruna Sarma
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Claire C. Yang
- Department of Urology, University of Washington, Seattle, Washington
| | - Michelle Taddeo
- Department of Medical Social Sciences, Northwestern University–Feinberg School of Medicine, Chicago, Illinois
| | - J. Quentin Clemens
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, Michigan
| | - Anne P. Cameron
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | | | - Victor Andreev
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Matthew O. Fraser
- Department of Surgery, Division of Urology, Duke University, Durham, North Carolina
| | - Bradley A. Erickson
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - James W. Griffith
- Department of Medical Social Sciences, Northwestern University–Feinberg School of Medicine, Chicago, Illinois
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21
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Hodgin JB, Mariani LH, Zee J, Liu Q, Smith AR, Eddy S, Hartman J, Hamidi H, Gaut JP, Palmer MB, Nast CC, Chang A, Hewitt S, Gillespie BW, Kretzler M, Holzman LB, Barisoni L. Quantification of Glomerular Structural Lesions: Associations With Clinical Outcomes and Transcriptomic Profiles in Nephrotic Syndrome. Am J Kidney Dis 2022; 79:807-819.e1. [PMID: 34864148 DOI: 10.1053/j.ajkd.2021.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/20/2021] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE The current classification system for focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) does not fully capture the complex structural changes in kidney biopsies nor the clinical and molecular heterogeneity of these diseases. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 221 MCD and FSGS patients enrolled in the Nephrotic Syndrome Study Network (NEPTUNE). EXPOSURE The NEPTUNE Digital Pathology Scoring System (NDPSS) was applied to generate scores for 37 glomerular descriptors. OUTCOME Time from biopsy to complete proteinuria remission, time from biopsy to kidney disease progression (40% estimated glomerular filtration rate [eGFR] decline or kidney failure), and eGFR over time. ANALYTICAL APPROACH Cluster analysis was used to group patients with similar morphologic characteristics. Glomerular descriptors and patient clusters were assessed for associations with outcomes using adjusted Cox models and linear mixed models. Messenger RNA from glomerular tissue was used to assess differentially expressed genes between clusters and identify genes associated with individual descriptors driving cluster membership. RESULTS Three clusters were identified: X (n = 56), Y (n = 68), and Z (n = 97). Clusters Y and Z had higher probabilities of proteinuria remission (HRs of 1.95 [95% CI, 0.99-3.85] and 3.29 [95% CI, 1.52-7.13], respectively), lower hazards of disease progression (HRs of 0.22 [95% CI, 0.08-0.57] and 0.11 [95% CI, 0.03-0.45], respectively), and lower loss of eGFR over time compared with X. Cluster X had 1,920 genes that were differentially expressed compared with Y+Z; these reflected activation of pathways of immune response and inflammation. Six descriptors driving the clusters individually correlated with clinical outcomes and gene expression. LIMITATIONS Low prevalence of some descriptors and biopsy at a single time point. CONCLUSIONS The NDPSS allows for categorization of FSGS/MCD patients into clinically and biologically relevant subgroups, and uncovers histologic parameters associated with clinical outcomes and molecular signatures not included in current classification systems.
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Affiliation(s)
- Jeffrey B Hodgin
- Renal Pathology, Department of Pathology, University of Michigan, Ann Arbor, Michigan.
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean Eddy
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Hartman
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Habib Hamidi
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Joseph P Gaut
- Department of Pathology and Immunology, and Internal Medicine, Washington University, St. Louis, Missouri
| | - Matthew B Palmer
- Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anthony Chang
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois
| | - Stephen Hewitt
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lawrence B Holzman
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Barisoni
- Department of Pathology, Division of AI & Computational Pathology, Duke University, Durham, North Carolina; Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina.
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22
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Zee J, Liu Q, Smith AR, Hodgin JB, Rosenberg A, Gillespie BW, Holzman LB, Barisoni L, Mariani LH. Kidney Biopsy Features Most Predictive of Clinical Outcomes in the Spectrum of Minimal Change Disease and Focal Segmental Glomerulosclerosis. J Am Soc Nephrol 2022; 33:1411-1426. [PMID: 35581011 PMCID: PMC9257823 DOI: 10.1681/asn.2021101396] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/01/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Heterogeneity in disease course and treatment response among patients with MCD/FSGS necessitates a granular evaluation of kidney tissue features. This study aimed to identify histologic and ultrastructural descriptors of structural changes most predictive of clinical outcomes in the Nephrotic Syndrome Study Network (NEPTUNE). METHODS Forty-eight histologic (37 glomerular, 9 tubulointerstitial, 2 vascular) and 20 ultrastructural descriptors were quantified by applying the NEPTUNE Digital Pathology Scoring System to NEPTUNE kidney biopsies. Outcomes included time from biopsy to disease progression, first complete remission of proteinuria, and treatment response. Relative importance of pathology and clinical predictors was obtained from random forest models, and predictive discrimination was assessed. RESULTS Among 224 participants (34% Black, 24% Hispanic), model performance was excellent, with predictive discrimination of 0.9 for disease progression, 0.85 for complete remission, and 0.81 for treatment response. The most predictive descriptors of outcomes included both conventional-e.g., global sclerosis or segmental sclerosis and interstitial fibrosis/tubular atrophy-and novel features, including adhesion, interstitial foam cells, deflation, periglomerular fibrosis, mononuclear white blood cells, endothelial cell abnormalities, microvillous transformation, and acute tubular injury. CONCLUSIONS The most predictive descriptors of clinical outcomes among MCD/FSGS patients reflected structural changes in multiple renal compartments. Reporting these descriptors should be standardized to guide prognostication of proteinuric glomerular diseases.
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Affiliation(s)
- Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeffrey B Hodgin
- Renal Pathology, Department of Pathology and Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland and Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Lawrence B Holzman
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Barisoni
- Department of Pathology, Division of AI and Computational Pathology, and Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina
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23
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Harte SE, Wiseman J, Wang Y, Smith AR, Yang CC, Helmuth M, Kreder K, Kruger GH, Gillespie BW, Amundsen C, Kirkali Z, Lai HH. Experimental Pain and Auditory Sensitivity in Overactive Bladder Syndrome: A Symptoms of the Lower Urinary Tract Dysfunction Research Network (LURN) Study. J Urol 2022; 207:161-171. [PMID: 34428922 PMCID: PMC9237822 DOI: 10.1097/ju.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to investigate the presence of nonbladder sensory abnormalities in participants with overactive bladder syndrome (OAB). MATERIALS AND METHODS Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) study participants with OAB symptoms and controls were recruited from 6 U.S. tertiary referral centers. Quantitative sensory testing (QST) was performed to determine pressure pain sensitivity at the thumbnail bed and auditory sensitivity. Fixed and mixed effect multivariable linear regressions and Weibull models were used to compare QST responses between groups. Pearson correlations were used to assess the relationship between QST measures. Associations between QST and self-reported symptoms were explored with linear regression. RESULTS A total of 297 participants were analyzed (191 OAB, 106 controls; 76% white, 51% male). OAB cases were older than controls (57.4 vs 52.2 years, p=0.015). No significant differences in experimental thumbnail (nonbladder) pain or auditory sensitivity were detected between OAB cases and controls. Correlations between pressure and auditory derived metrics were weak to moderate overall for both groups, with some significantly stronger correlations for cases. Exploratory analyses indicated increased pressure pain and auditory sensitivity were modestly associated with greater self-reported bladder pain and pain interference with physical function. CONCLUSIONS As a group, no significant differences between OAB cases and controls were observed in experimental nonbladder pain or auditory sensitivity during QST. Associations between QST outcomes and clinical pain raise the possibility of centrally mediated sensory amplification in some individuals with OAB.
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Affiliation(s)
- Steven E. Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jon Wiseman
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
| | - Ying Wang
- Department of Anesthesia, Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Claire C. Yang
- Department of Urology, University of Washington, Seattle, WA, 98195-6510 USA
| | | | - Karl Kreder
- Department of Urology, University of Iowa, Iowa City, IA, USA
| | - Grant H. Kruger
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Cindy Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
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Pritchard CE, Williams AP, Davies P, Jones D, Smith AR. Spatial behaviour of sheep during the neonatal period: Preliminary study on the influence of shelter. Animal 2021; 15:100252. [PMID: 34090091 DOI: 10.1016/j.animal.2021.100252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Effective shelter has been demonstrated to reduce neonatal lamb mortality rates during periods of inclement weather. Periods of high wind speed and rainfall have been shown to influence shelter usage; however, it is not yet known how ewe factors such as breed, age and body condition score influence shelter-seeking behaviour. This study, conducted on a working upland farm in the UK, examined impact of artificial shelter on the biological and climatic factors that influence peri-parturient ewe behaviour. Pregnant ewes (n = 147) were randomly allocated between two adjacent fields which were selected for their similarity in size, topography, pasture management, orientation to the prevailing wind and available natural shelter. In one field, three additional artificial shelters were installed to increase the available shelter for ewes, this field was designated the Test field; no additional artificial shelter was provided in the second field which was used as the Control field. Individual ewes were observed every 2 h between 0800 and 1600 for 14 continuous days to monitor their location relative to shelter. Ewe breed (Aberfield and Highlander), age (2-8 years) and body condition score were considered as explanatory variables to explain flock and individual variance in shelter-seeking behaviour and the prevalence of issues which required the intervention of the shepherd, termed 'shepherding problems'. Any ewe observed with dystocia, a dead or poor vigour lamb or who exhibited mismothering behaviour was recorded as a shepherding problem. The prevalence of these shepherding problems which necessitate human intervention represents arguably the most critical limiting factor for the successful management of commercial sheep flocks in outdoor lambing systems. Overall, ewes in the Test field with access to additional artificial shelter experienced fewer shepherding problems than those in the Control field (P < 0.05). A significant breed effect was also observed, with Highlander ewes more likely to seek shelter than Aberfield ewes (P < 0.001), and experiencing significantly fewer shepherding interventions (P < 0.05). These findings demonstrate the substantial and significant benefits to animal welfare and productivity that can be achieved through the provision of shelter in commercial, upland, outdoor lambing systems in the UK.
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Affiliation(s)
- C E Pritchard
- School of Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2DG, UK
| | - A P Williams
- School of Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2DG, UK.
| | - P Davies
- Department of Livestock & One Health, Institute of Infection, University of Liverpool, Neston, CH64 7TE, UK
| | - D Jones
- Innovis Ltd., Capel Dewi, Aberystwyth SY23 3HU, UK
| | - A R Smith
- School of Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2DG, UK
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25
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Geynisman-Tan J, Helmuth M, Smith AR, Lai HH, Amundsen CL, Bradley CS, Mueller MG, Lewicky-Gaupp C, Harte SE, Jelovsek JE. Prevalence of childhood trauma and its association with lower urinary tract symptoms in women and men in the LURN study. Neurourol Urodyn 2021; 40:632-641. [PMID: 33508156 DOI: 10.1002/nau.24613] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/07/2020] [Accepted: 12/24/2020] [Indexed: 11/12/2022]
Abstract
AIMS To describe the association between childhood traumas (death of a family member, severe illness, sexual trauma, parental separation) reported by women and men and lower urinary tract symptoms (LUTS). METHODS In this secondary analysis of the Lower Urinary Tract Research Network Observational Cohort Study, participants completed the LUTS tool, childhood trauma events scale (CTES), PROMIS depression and anxiety and perceived stress scale. LUTS tool responses were combined to quantify urinary urgency, frequency, incontinence, and overall LUTS severity. Multivariable linear regression tested associations between trauma and LUTS; mental health scores were tested for potential mediation. RESULTS In this cohort (n = 1011; 520 women, 491 men), more women reported experiencing at least one trauma (75% vs. 64%, p < .001), greater than three traumas (26% vs. 15%, p < .001), and childhood sexual trauma (23% vs. 7%, p < .001), and reported higher impact from traumatic events compared with men (median [interquartile rnage] CTES score = 10 [5-15] vs. 6 [4-12], p < .001). The number of childhood traumatic events was not associated with severity of overall LUTS (p = .79), urinary frequency (p = .75), urgency (p = .61), or incontinence (p = .21). Childhood sexual trauma was significantly associated with higher incontinence severity (adjusted mean difference 4.5 points, 95% confidence interval= 1.11-7.88, p = .009). Mental health was a mediator between trauma and LUTS among those with at least one childhood trauma. CONCLUSION Although total childhood trauma is not associated with LUTS, childhood sexual trauma is associated with urinary incontinence severity. For patients with childhood trauma, half of the effect of CTE Impact score on overall LUTS severity is mediated through the association between trauma and the patient's mental health.
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Affiliation(s)
- Julia Geynisman-Tan
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, USA
| | - Margaret Helmuth
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - H Henry Lai
- Departments of Surgery (Urology) and Anesthesiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa, USA
| | - Margaret G Mueller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, USA
| | | | - Steven E Harte
- Departments of Anesthesiology and Internal Medicine-Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
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26
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Agochukwu-Mmonu N, Wiseman JB, Smith AR, Helmuth ME, Sarma AV, Cameron AP, Amundsen CL, Flynn KE, Cella D, Weinfurt KP, Kirkali Z, Clemens JQ. Relationship of symptom severity and bother in individuals seeking care for lower urinary tract symptoms. Neurourol Urodyn 2020; 39:2161-2170. [PMID: 32761962 DOI: 10.1002/nau.24466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/03/2020] [Accepted: 07/03/2020] [Indexed: 11/05/2022]
Abstract
AIMS Bother attributed to lower urinary tract symptoms (LUTS) drives care-seeking and treatment aggressiveness. The longitudinal relationship of LUTS severity and bother in a care-seeking cohort, however, is not well understood. We aim to conduct a longitudinal evaluation of LUTS severity and bother and identify characteristics of patients with discordant LUTS bother relative to severity. METHODS Men and women with LUTS seeking care at six US tertiary care centers enrolled in the symptoms of lower urinary tract dysfunction research network study. Patients reporting at least one urinary symptom based on the LUTS Tool were prospectively enrolled from June 2015 to January 2017. Correlations were used to assess the relationship between LUTS severity and bother. Discordance scores (ie, the difference between bother and severity) were used to classify patients with high and low bother. Patients were classified as having high or low bother phenotypes if scores were one standard deviation above or below zero, respectively. Repeated measures multinomial logistic regression evaluated characteristics associated with high and low bother phenotypes. RESULTS LUTS severity and bother were at least moderately correlated for all symptom items and highly correlated for 13 out of 21 items. Correlations were highest for urgency, and lowest for daytime frequency and urinary incontinence. Odds of being in high bother phenotype were lowest at 3 and 12 months (3 months vs baseline odds ratio [OR] = 0.71, 95% confidence ninterval [CI] = 0.54-0.94; 12 months vs baseline OR = 0.66, 95% CI = 0.48-0.91), and highest for those who endorsed all urgency questions (OR = 3.65, 95% CI = 2.17-6.13). Odds of being in the low bother phenotype were lowest for patients who endorsed all urgency items (OR = 0.33, 95% CI = 0.26-0.42), and all frequency items (OR = 0.68, 95% CI = 0.53-0.88). CONCLUSIONS LUTS severity and bother correlate highly and measurement of both in clinical practice is likely redundant. There are patient factors associated with discordance which may justify additional evaluation.
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Affiliation(s)
- Nnenaya Agochukwu-Mmonu
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan.,Department of Urology, New York University Langone Medical Center, New York, New York
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Aruna V Sarma
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan
| | - Anne P Cameron
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Kevin P Weinfurt
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - J Quentin Clemens
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan
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Flynn KE, Mansfield SA, Smith AR, Gillespie BW, Bradley CS, Cella D, Helmuth ME, Lai HH, Kirkali Z, Talaty P, Griffith JW, Weinfurt KP. Patient demographic and psychosocial characteristics associated with 30-day recall of self-reported lower urinary tract symptoms. Neurourol Urodyn 2020; 39:1939-1948. [PMID: 32856723 DOI: 10.1002/nau.24461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 11/09/2022]
Abstract
AIMS Measurement of self-reported lower urinary tract symptoms (LUTS) typically uses a recall period, for example, "In the past 30 days…." Compared to averaged daily reports, 30-day recall is generally unbiased, but recall bias varies by item. We examined the associations between personal characteristics (eg, age, symptom bother) and 30-day recall of LUTS using items from the Symptoms of Lower Urinary Tract Dysfunction Research Network Comprehensive Assessment of Self-reported Urinary Symptoms questionnaire. METHODS Participants (127 women and 127 men) were recruited from 6 US tertiary care sites. They completed daily assessments for 30 days and a 30-day recall assessment at the end of the study month. For each of the 18 tested items, representing 10 LUTS, the average of the participant's daily responses was modeled as a function of their 30-day recall, the personal characteristic, and the interaction between the 30-day recall and the characteristic in separate general linear regression models, adjusted for sex. RESULTS Nine items representing 7 LUTS exhibited under- or overreporting (recall bias) for at least 25% of participants. Bias was associated with personal characteristics for six LUTS. Underreporting of incontinence was associated with older age, lower anxiety, and negative affect; overreporting of other LUTS was associated with, symptom bother, symptom variability, anxiety, and depression. CONCLUSIONS We identified under- or overreporting that was associated with personal characteristics for six common LUTS. Some cues (eg, less bother and lower anxiety) were related to recall bias in an unexpected direction. Thus, providers should exercise caution when making judgments about the accuracy of a patient's symptom recall based on patient demographic and psychosocial characteristics.
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Affiliation(s)
- Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - David Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | | | - H Henry Lai
- Division of Urologic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ziya Kirkali
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Pooja Talaty
- NorthShore University Health System, Glenview, Illinois
| | - James W Griffith
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
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28
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Flynn KE, Mansfield SA, Smith AR, Gillespie BW, Bradley CS, Cella D, Helmuth ME, Henry Lai H, Kirkali Z, Talaty P, Weinfurt KP. MP27-02 PERSONAL CHARACTERISTICS ASSOCIATED WITH 30-DAY RECALL OF SELF-REPORTED LOWER URINARY TRACT SYMPTOMS. J Urol 2020. [DOI: 10.1097/ju.0000000000000866.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith AR, Nelson EE, Kircanski K, Rappaport BI, Do QB, Leibenluft E, Pine DS, Jarcho JM. Social anxiety and age are associated with neural response to social evaluation during adolescence. Dev Cogn Neurosci 2020; 42:100768. [PMID: 32077442 PMCID: PMC7030986 DOI: 10.1016/j.dcn.2020.100768] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/15/2022] Open
Abstract
Adolescence is a sensitive period for the development of adaptive social behaviors and social anxiety, possibly due to aspects of brain development. However, research is needed to examine interactions among age, social anxiety, and social dynamics previously shown to influence neural responding. The current functional magnetic resonance imaging (fMRI) study examines brain function in 8-18 year-olds with varying levels of social anxiety. Interactions are examined among age, social anxiety, and two key task factors: valence and predictability of social interactions. Results demonstrate age, social anxiety severity, and each of the two key task-based factors interact to predict neural response in the caudate, middle and superior temporal gyri. In particular, among adolescents less-than 13 years of age, higher social anxiety predicted greater responding to unpredictable negative evaluations. However, in this same age group, the opposite pattern emerged during receipt of unpredictable positive evaluations, with less neural response in more anxious youth. Adolescents aged 13 and older overall showed less robust effects. We discuss these findings in terms of age- and anxiety-related differences in socioemotional processing.
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Affiliation(s)
- A R Smith
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD United States.
| | - E E Nelson
- Center for Biobehavioral Health, Research Institute at Nationwide Children's Hospital, Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH United States
| | - K Kircanski
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD United States
| | - B I Rappaport
- Department of Psychological & Brain Sciences, Washington University in St. Louis, St. Louis, Missouri United States
| | - Q B Do
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania United States
| | - E Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD United States
| | - D S Pine
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD United States
| | - J M Jarcho
- Department of Psychology, Temple University, Philadelphia, Pennsylvania United States
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30
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Clemens JQ, Wiseman JB, Smith AR, Amundsen CL, Yang CC, Bradley MS, Kirkali Z, Agochukwu NQ, Cameron AP. Prevalence, subtypes, and correlates of nocturia in the symptoms of Lower Urinary Tract Dysfunction Research Network cohort. Neurourol Urodyn 2020; 39:1098-1107. [PMID: 32249998 PMCID: PMC7238757 DOI: 10.1002/nau.24338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Abstract
AIMS We determined the prevalence, severity, and correlates of nocturia in a large clinical cohort of patients. METHODS Patients presenting with lower urinary tract symptoms (LUTS) completed 3-day bladder diaries. Nocturia was quantified based on the mean number of nighttime voids documented over the 3 days. Nocturia subtypes (global polyuria, nocturnal polyuria [NP], reduced global bladder capacity, and reduced nocturnal bladder capacity) were assessed. Bother due to nocturia was measured by the LUTS Tool. Sleep quality was assessed with the Patient-Reported Outcomes Measurement Information System Sleep Scale. Multivariable multinomial regression was used to explore patient characteristics associated with nocturia. RESULTS In 502 participants with analyzable diaries (285 men and 217 women), the mean number of nocturia episodes over 3 days was 0 in 103 (20.5%), >0 to <1 in 151 (20.1%), 1 to <2 in 165 (32.9%), and ≥2 in 83 (16.5%). Sixty-seven percent of the participants with nocturia ≥1 reported significant bother from their nocturia. NP was the most common nocturia subtype and was present in 17% of those with nocturia = 0, 40% of those with nocturia >0 to <1, 65% of those with nocturia 1 to <2%, and 77% with nocturia 2+. Higher degrees of nocturia were associated with male sex, greater sleep disturbance, and a higher likelihood of exhibiting multiple nocturia subtypes. CONCLUSIONS Nocturia ≥1 occurred in 49% of LUTS patients and caused significant bother in the majority of them. The most common subtype was NP, but a substantial proportion of patients exhibited additional characteristics.
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Affiliation(s)
| | | | | | - Cindy L. Amundsen
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Claire C. Yang
- Department of Urology, University of Washington, Seattle, Washington
| | - Megan S. Bradley
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | | | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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31
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Royal V, Zee J, Liu Q, Avila-Casado C, Smith AR, Liu G, Mariani LH, Hewitt S, Holzman LB, Gillespie BW, Hodgin JB, Barisoni L. Ultrastructural Characterization of Proteinuric Patients Predicts Clinical Outcomes. J Am Soc Nephrol 2020; 31:841-854. [PMID: 32086276 DOI: 10.1681/asn.2019080825] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/31/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The analysis and reporting of glomerular features ascertained by electron microscopy are limited to few parameters with minimal predictive value, despite some contributions to disease diagnoses. METHODS We investigated the prognostic value of 12 electron microscopy histologic and ultrastructural changes (descriptors) from the Nephrotic Syndrome Study Network (NEPTUNE) Digital Pathology Scoring System. Study pathologists scored 12 descriptors in NEPTUNE renal biopsies from 242 patients with minimal change disease or FSGS, with duplicate readings to evaluate reproducibility. We performed consensus clustering of patients to identify unique electron microscopy profiles. For both individual descriptors and clusters, we used Cox regression models to assess associations with time from biopsy to proteinuria remission and time to a composite progression outcome (≥40% decline in eGFR, with eGFR<60 ml/min per 1.73 m2, or ESKD), and linear mixed models for longitudinal eGFR measures. RESULTS Intrarater and interrater reproducibility was >0.60 for 12 out of 12 and seven out of 12 descriptors, respectively. Individual podocyte descriptors such as effacement and microvillous transformation were associated with complete remission, whereas endothelial cell and glomerular basement membrane abnormalities were associated with progression. We identified six descriptor-based clusters with distinct electron microscopy profiles and clinical outcomes. Patients in a cluster with more prominent foot process effacement and microvillous transformation had the highest rates of complete proteinuria remission, whereas patients in clusters with extensive loss of primary processes and endothelial cell damage had the highest rates of the composite progression outcome. CONCLUSIONS Systematic analysis of electron microscopic findings reveals clusters of findings associated with either proteinuria remission or disease progression.
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Affiliation(s)
- Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada;
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Carmen Avila-Casado
- Department of Laboratory Medicine, University of Toronto, Scarborough, Ontario, Canada
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Gang Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Stephen Hewitt
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lawrence B Holzman
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey B Hodgin
- Renal Pathology, Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Laura Barisoni
- Department of Pathology, Duke University, Durham, North Carolina
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Schimpf MO, Smith AR, Miller JM. Fluids affecting bladder urgency and lower urinary symptoms (FABULUS): methods and protocol for a randomized controlled trial. Int Urogynecol J 2019; 31:1033-1040. [PMID: 31875256 DOI: 10.1007/s00192-019-04209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We present the design of a randomized controlled trial, Fluids Affecting Bladder Urgency and Lower Urinary Symptoms (FABULUS), with the purpose of testing the common clinical advice of treating overactive bladder by eliminating potentially irritating beverages (PIBs) that are caffeinated, artificially sweetened, citric, or alcoholic. The primary hypothesis is that women taught to reduce PIBs will show less void frequency compared with a control group instructed in diet/exercise recommendations. Secondary outcomes include change in urgency symptoms and volume per void. METHODS We report the methods for FABULUS and discuss how challenges presented in the literature and from a prior proof-of-concept feasibility trial are addressed by strengthening study design, procedures, and instruments. We introduce the concept of standardized automated tutorials for assisting participants in compliance from study start to finish. The tutorials contain a detailed explanation of the study, including tips for complying with the extensive diary requirements, and parallel tutorials to intervention and control groups for consistency in format and time of instructional content. The intervention tutorial on eliminating PIBs places emphasis on maintaining steady fluid intake volume, as fluctuations have been a confounder in prior work. RESULTS Study results promise to inform about both the tutorial approach and specific PIB reduction for effectively treating overactive bladder. CONCLUSIONS OAB can have a negative impact on quality of life, and current medical treatments carry costs and side-effect risks. If simple lifestyle changes can improve or prevent these bladder symptoms, multiple medical and public health advances could result.
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Affiliation(s)
- Megan O Schimpf
- Department of Obstetrics and Gynecology, Division of Gynecology, University of Michigan, L4000 University Hospital South, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | | | - Janis M Miller
- Department of Obstetrics and Gynecology, Division of Gynecology, University of Michigan, L4000 University Hospital South, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
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Williams AM, Barrett M, Smith AR, Kathawate RG, Woodside KJ, Sung RS. Variable Benefits of Antibody Induction by Kidney Allograft Type. J Surg Res 2019; 248:69-81. [PMID: 31865161 DOI: 10.1016/j.jss.2019.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 09/26/2019] [Accepted: 11/16/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Kidneys from acute renal failure (ARF), expanded criteria donors (ECD), and donation after cardiac death (DCD) donors are often discarded due to concerns for delayed graft function (DGF) and graft failure. Induction immunosuppression may be used to minimize these risks, but practices vary widely. Furthermore, little is known regarding national outcomes of transplant recipients receiving induction immunosuppression for receipt of high-risk kidneys. MATERIALS AND METHODS Using a center-level retrospective study, deceased donor transplants (115,485) from the Scientific Registry of Transplant Recipients from January 2003 to June 2016 were evaluated. Patients who received induction immunosuppression, including lymphocyte immune globulin, muromonab CD-3, IL-1 receptor antagonist, anti-thymocyte globulin, daclizumab, basiliximab, alemtuzumab, and rituximab, were included. Associations of center-level induction use with acute rejection in the first post-transplant year, graft failure, and patient mortality were evaluated using multivariable Cox and logistic regression. RESULTS Among all kidneys, increasing percentage of center-level induction was associated with lower risk of graft failure, acute rejection, and patient mortality. In recipients of ARF kidneys, the beneficial association of induction on graft failure and acute rejection was greater than in those that received non-ARF kidneys. Marginally greater benefit of induction was seen for acute rejection in ECD compared to standard criteria donor (SCD) recipients and for graft failure in DCD compared to donors after brain death (DBD). No benefit of induction was detected for patient and graft survival in ECD recipients, acute rejection in DCD recipients, and patient survival in DGF recipients. No difference in the benefit of induction was detected in any other comparisons. CONCLUSIONS While seemingly beneficial for recipients of all kidneys, induction has more robust associations with lower graft failure and acute rejection probability for recipients of ARF kidneys. Given the lack of observed benefit for ECD recipients, induction policies should be carefully considered in these patients.
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Affiliation(s)
- Aaron M Williams
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Meredith Barrett
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Ranganath G Kathawate
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kenneth J Woodside
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Randall S Sung
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Miller JM, Hawthorne KM, Park L, Tolbert M, Bies K, Garcia C, Misiunas R, Newhouse W, Smith AR. Self-Perceived Improvement in Bladder Health After Viewing a Novel Tutorial on Knack Use: A Randomized Controlled Trial Pilot Study. J Womens Health (Larchmt) 2019; 29:1319-1327. [PMID: 31800360 DOI: 10.1089/jwh.2018.7606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To test a novel bladder health tutorial on use of the Knack for overcoming bladder control challenges. The Knack-tutorial is a self-administered vignette-based instructional program on preempting bladder challenges in daily life (urgency, stress-leakage, or urge-leakage) through anticipatory, well-timed pelvic floor muscle contraction at the moment of challenge. Materials and Methods: This is a randomized controlled trial pilot test of 108 women with stress or mixed urinary incontinence. The Knack-tutorial group saw a 15-minute slide show with 10 vignettes portraying use of the Knack in daily life. The slide show format used inserted narrated videos, dubbed and animation enhanced pictures and cartoons, and automatic slide advancement. A control group saw a similarly constructed slide show on incorporating good diet/exercise habits. Outcomes were self-perceived improvement (yes/no, and as 0%-100%) 1 month after viewing the tutorial. Results: We enrolled 123 women, randomizing 64 to Knack-tutorial group and 59 to diet/exercise tutorial group. Eleven and one participant, respectively, did not return. Three did not fill out the self-perceived improvement report. Significant improvement was reported by 71% in the Knack-tutorial group compared to 25% in the diet/exercise group (p < 0.001). Self-perceived improvement was 21%-22% higher (Model I Est: 21.01, SE: 4.25, p < 0.001) in the Knack-tutorial group. Conclusions: An electronic tutorial viewed independent of a health care provider with vignettes showing Knack application to manage the everyday bladder challenges women face shows benefit of a magnitude that warrants more widespread use and rigorous testing. A professional remake of the intervention is now available (www.myconfidentbladder.com).
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Affiliation(s)
- Janis M Miller
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - Lee Park
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Margaret Tolbert
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Katie Bies
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Caroline Garcia
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Ruta Misiunas
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - William Newhouse
- Center for Health Communications Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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Liu G, Andreev VP, Helmuth ME, Yang CC, Lai HH, Smith AR, Wiseman JB, Merion RM, Erickson BA, Cella D, Griffith JW, Gore JL, DeLancey JOL, Kirkali Z. Symptom Based Clustering of Men in the LURN Observational Cohort Study. J Urol 2019; 202:1230-1239. [PMID: 31120372 PMCID: PMC6842034 DOI: 10.1097/ju.0000000000000354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE Conventional classification of patients with lower urinary tract symptoms into diagnostic categories based on a predefined symptom complex or predominant symptom appears inadequate. This is due to the frequent presentation of patients with multiple urinary symptoms which could not be perfectly categorized into traditional diagnostic groups. We used a novel clustering method to identify subtypes of male patients with lower urinary tract symptoms based on detailed multisymptom information. MATERIALS AND METHODS We analyzed baseline data on 503 care seeking men in the LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) Observational Cohort Study. Symptoms and symptom severity were assessed using the LUTS (Lower Urinary Tract Symptoms) Tool and the AUA SI (American Urological Association Symptom Index), which include a total of 52 questions. We used a resampling based consensus clustering algorithm to identify patient subtypes with distinct symptom signatures. RESULTS Four distinct symptom clusters were identified. The 166 patients in cluster M1 had predominant symptoms of frequency, nocturia, hesitancy, straining, weak stream, intermittency and incomplete bladder emptying suggestive of bladder outlet obstruction. The 93 patients in cluster M2 mainly endorsed post-micturition symptoms (eg post-void dribbling and post-void leakage) with some weak stream. The 114 patients in cluster M3 reported mostly urinary frequency without incontinence. The 130 patients in cluster M4 reported severe frequency, urgency and urgency incontinence. Most other urinary symptoms statistically differed between cluster pairs. Patient reported outcomes of bowel symptoms, mental health, sleep dysfunction, erectile function and urological pain significantly differed across the clusters. CONCLUSIONS We identified 4 data derived clusters among men seeking care for lower urinary tract symptoms. The clusters differed from traditional diagnostic categories. Further subtype refinement will be done to incorporate clinical data and nonurinary patient reported outcomes.
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Affiliation(s)
- Gang Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | | | | | - H. Henry Lai
- Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | | | | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Amundsen CL, Helmuth ME, Smith AR, DeLancey JOL, Bradley CS, Flynn KE, Kenton KS, Henry Lai H, Cella D, Griffith JW, Andreev VP, Eric Jelovsek J, Liu AB, Kirkali Z, Yang CC. Longitudinal changes in symptom-based female and male LUTS clusters. Neurourol Urodyn 2019; 39:393-402. [PMID: 31765491 DOI: 10.1002/nau.24219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/31/2019] [Indexed: 11/09/2022]
Abstract
AIMS Lower urinary tract symptoms (LUTS) are diverse in type and variable in severity. We examined symptom change within the Symptoms of the Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort study identified clusters over time and tested associations with treatments received. METHODS Patient-reported LUTS and treatment data were collected at multiple time points between baseline and 12 months from the LURN Observational Cohort study. LUTS severity scores were calculated to summarize changes in symptom reporting over time in previously identified LURN clusters. Repeated measures linear regression models tested adjusted associations between cluster membership and severity scores. RESULTS Four-hundred seventeen men and 396 women were classified into improved, unchanged, and worsened symptoms between baseline and 12 months (men: 44.1%, 40.5%, and 15.3%; women: 55.8%, 33.1%, 11.1%, respectively). Improvement in LUTS severity scores varied by cluster (estimated adjusted mean change from baseline range: -.04 change in standard deviations of severity scores (ΔSD) to -.67 ΔSD). Prostate surgery was associated with improved severity scores (-.63 ΔSD) in men, while stress incontinence surgery was associated with improved severity scores (-.88 ΔSD) in women. CONCLUSION Symptom improvement varied by cluster indicating response to therapy differs amongst subtypes of patients with LUTS. The differential improvement of patients in clusters suggests mechanistic differences between clusters and may aid in selecting more targeted treatments in the future.
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Affiliation(s)
- Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | | | - Kimberly S Kenton
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - H Henry Lai
- Washington University School of Medicine, St. Louis, Missouri
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James W Griffith
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Alice B Liu
- University of Washington, Seattle, Washington
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Liu Q, Smith AR, Mariani LH, Nair V, Zee J. Methods for Assessing Longitudinal Biomarkers of Time-to-Event Outcomes in CKD: A Simulation Study. Clin J Am Soc Nephrol 2019; 14:1315-1323. [PMID: 31416887 PMCID: PMC6730514 DOI: 10.2215/cjn.00450119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/03/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Identifying novel biomarkers is critical to advancing diagnosis and treatment of CKD, but relies heavily on the statistical methods used. Inappropriate methods can lead to both false positive and false negative associations between biomarkers and outcomes. This study assessed accuracy of methods using computer simulations and compared biomarker association estimates in the NEPhrotic syndrome sTUdy NEtwork (NEPTUNE), a prospective cohort study of patients with glomerular disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compared three methods for analyzing repeatedly measured biomarkers in proportional hazards models: (1) time-invariant average, that averages values over all follow-up and uses the average as a baseline covariate, (2) time-varying last observation carried forward (LOCF), that assumes the covariate is unchanged until the next observed value, and (3) time-varying cumulative average, that updates the average using values at or before each measurement. RESULTS Under both true mechanisms of LOCF and cumulative average, simulation results showed the time-invariant average method often gave extremely inaccurate results. When LOCF was the true association mechanism, the cumulative average method often gave overestimated association estimates that were further away from the null. When cumulative average was the true mechanism, LOCF always underestimated the associations, i.e., closer to the null. In NEPTUNE, compared with the LOCF or cumulative average methods, hazard ratios estimated from the time-invariant average method were always higher. CONCLUSIONS Different analytic methods resulted in markedly different results. Using the time-invariant average produces inaccurate association estimates, whereas other methods can estimate additive (cumulative average) or instantaneous (LOCF) associations depending on the hypothesized underlying association mechanism and research question.
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Affiliation(s)
- Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Laura H Mariani
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and.,Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Viji Nair
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
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Peterson AC, Smith AR, Fraser MO, Yang CC, DeLancey JOL, Gillespie BW, Gore JL, Talaty P, Andreev VP, Kreder KJ, Mueller MG, Lai HH, Erickson BA, Kirkali Z. The Distribution of Post-Void Residual Volumes in People Seeking Care in the Symptoms of Lower Urinary Tract Dysfunction Network Observational Cohort Study With Comparison to Asymptomatic Populations. Urology 2019; 130:22-28. [PMID: 31018115 PMCID: PMC6660395 DOI: 10.1016/j.urology.2019.01.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the distribution of post-void residual (PVR) volumes across patients with and without lower urinary tract symptoms (LUTS) and examine relationships between self-reported voiding symptoms, storage symptoms, and PVR. METHODS PVR and demographic data were obtained from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) observational cohort study. Self-reported symptoms were collected using the American Urological Association Symptom Index and the LUTS Tool. PVR values were obtained from 2 other cohorts: living kidney donors with unknown LUTS from the Renal and Lung Living Donors Evaluation Study (RELIVE), and continent women in the Establishing the Prevalence of Incontinence (EPI) study, a population-based study of racial differences in urinary incontinence prevalence. RESULTS Across the 3 studies, median PVRs were similar: 26 mL in LURN (n = 880, range 0-932 mL), 20 mL in EPI (n = 166, range 0-400 mL), and 14 mL in RELIVE (n = 191, range 0-352 mL). In LURN, males had 3.6 times higher odds of having PVR > 200 mL (95% CI = 1.72-7.48). In RELIVE, median PVR was significantly higher for males (20 mL vs 0 mL, P= .004). Among women, only the intermittency severity rating was associated with a probability of an elevated PVR. Among men, incomplete emptying and burning severity rating were associated with a higher odds of elevated PVR, but urgency severity ratings were associated with lower odds of elevated PVR. CONCLUSION Care-seeking patients have PVRs similar to those in people with unknown history of LUTS (RELIVE) and without self-reported LUTS (EPI). Although PVR was correlated with voiding symptoms, the mean differences only explain ∼2% of the variance.
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Affiliation(s)
| | | | | | | | | | | | | | - Pooja Talaty
- NorthShore University Health System, Glenview, IL
| | | | | | | | - H Henry Lai
- Washington University School of Medicine, St. Louis, MO
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Cameron AP, Wiseman JB, Smith AR, Merion RM, Gillespie BW, Bradley CS, Amundsen CL, Yang CC, Lai HH, DeLancey JOL, Helmuth ME, Bradley MS, Agochukwu N, Andreev VP, Kirkali Z, Clemens JQ. Are three-day voiding diaries feasible and reliable? Results from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) cohort. Neurourol Urodyn 2019; 38:2185-2193. [PMID: 31347211 DOI: 10.1002/nau.24113] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/03/2019] [Indexed: 11/08/2022]
Abstract
AIMS The aims of this study were to assess the completeness of voiding diaries in a research context and to correlate diary data with patient-reported questionnaires. METHODS Men and women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) were given a 3-day voiding and fluid-intake diary to fill-out. Diaries were assessed for completeness and intake-output imbalances. They were assigned to one of four categories based on a percentage of missing data and fluid imbalance: no diary submitted, unusable (>40% missing void or intake volumes, or unphysiological fluid imbalance), usable but not complete, and complete. RESULTS A total of 1064 participants were enrolled and 85% (n = 902) returned the bladder diary. Of the diaries returned, 94% (n = 845) had data on three separate days, 87% (n = 786) had no missing intake volumes, 61% (n = 547) had no missing voided volumes, and 70% (n = 635) had a fluid imbalance within 3 L across the 3-day time period, resulting in 50% (n = 448) of participants with 100% complete diaries. Younger age was associated with a higher likelihood of not submitting a diary, or submitting an unusable diary. Women had a higher likelihood of submitting an unusable diary or a usable but incomplete diary. CONCLUSION Overall, 50% of LURN participants returned voiding diaries with perfectly complete data. Incomplete data for voided volumes was the most common deficiency. There was only a moderate correlation between diary data and questionnaire responses, indicating that diaries are a source of unique information.
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Affiliation(s)
- Anne P Cameron
- Departments of Urology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brenda W Gillespie
- Departments of Urology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Catherine S Bradley
- Iowa Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Cindy L Amundsen
- Duke Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, Washington
| | - Henry H Lai
- Department of Urology, Washington University School of Medicine, St Louis, Missouri
| | - John O L DeLancey
- Departments of Urology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Megan S Bradley
- Duke Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Nnena Agochukwu
- Departments of Urology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - J Quentin Clemens
- Departments of Urology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Cella D, Smith AR, Griffith JW, Flynn KE, Bradley CS, Gillespie BW, Kirkali Z, Talaty P, Jelovsek JE, Helfand BT, Weinfurt KP. A new outcome measure for LUTS: Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29) questionnaire. Neurourol Urodyn 2019; 38:1751-1759. [PMID: 31225927 DOI: 10.1002/nau.24067] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/25/2019] [Accepted: 05/21/2019] [Indexed: 11/09/2022]
Abstract
AIMS To develop a representative, self-report assessment of lower urinary tract symptoms (LUTS) for men and women, the symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29). METHODS Women and men seeking treatment for LUTS at one of six academic medical centers in the US were assessed at baseline, 3-month and 12-month intervals. Twelve-month data on 78 LURN SI-29 items were analyzed among 353 women and 420 men using exploratory factor analysis (EFA), with factor structure confirmed using confirmatory factor analysis (CFA). Internal consistency, reliability, and validity of the five developed scales were evaluated by assessing correlations with the American Urological Association Symptom Index (AUA-SI), the genitourinary pain index (GUPI), and the Pelvic Floor Distress Inventory-20 (PFDI-20), and by examining expected sex differences in scores. RESULTS EFA results (n = 150 women; 150 men) produced an interpretable eight-factor solution, with three of the factors comprised of dichotomous items addressing LUTS-associated sensations. The remaining five factors, confirmed with CFA in an independent sample of 473 participants, produced five scales: incontinence, urgency, voiding difficulty, bladder pain, and nocturia. Subscales and total LURN SI-29 scores were correlated as expected with AUA-SI, GUPI, and PFDI-20. LURN SI-29 scores also performed as expected in differentiating men from women based upon clinically expected differences, with men reporting more voiding difficulties and nocturia, and women reporting more urgency and incontinence. CONCLUSIONS The LURN SI-29 questionnaire has the potential to improve research and clinical outcome measurement for both men and women with LUTS.
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Affiliation(s)
- David Cella
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - James W Griffith
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Pooja Talaty
- NorthShore University Health System, Glenview, Illinois
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
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Tucker EL, Smith AR, Daskin MS, Schapiro H, Cottrell SM, Gendron ES, Hill-Callahan P, Leichtman AB, Merion RM, Gill SJ, Maass KL. Life and expectations post-kidney transplant: a qualitative analysis of patient responses. BMC Nephrol 2019; 20:175. [PMID: 31096942 PMCID: PMC6524208 DOI: 10.1186/s12882-019-1368-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The effect of a kidney transplant on a recipient extends beyond the restoration of kidney function. However, there is limited qualitative analysis of recipient perspectives on life following transplantation, particularly in the United States. To understand the full patient experience, it is necessary to understand recipient views on life adjustments after kidney transplantation, medical management, and quality of life. This could lead to improvements in recipient care and sense of well-being. METHODS We conducted a paper-based survey from March 23 to October 1, 2015 of 476 kidney transplant recipients at the University of Michigan Health System in Ann Arbor, Michigan. We analyzed their open-ended responses using qualitative research methods. This is a companion analysis to a previous quantitative report on the closed-ended responses to that survey. RESULTS Common themes relating to changes following transplantation included: improvements in quality of life, a return to normalcy, better health and more energy. Concerns included: duration of graft survival, fears about one day returning to dialysis or needing to undergo another kidney transplant, comorbidities, future quality of life, and the cost and quality of their healthcare. Many recipients were grateful for their transplant, but some were anxious about the burdens transplantation placed on their loved ones. CONCLUSIONS While most recipients reported meaningful improvements in health and lifestyle after kidney transplantation, a minority of participants experienced declines in energy or health status. Worries about how long the transplant will function, future health, and cost and quality of healthcare are prevalent. Future research could study the effects of providing additional information, programs, and interventions following transplantation that target these concerns. This may better prepare and support kidney recipients and lead to improvements in the patient experience.
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Affiliation(s)
- Emily L. Tucker
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | | | - Mark S. Daskin
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Hannah Schapiro
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Sabrina M. Cottrell
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Evelyn S. Gendron
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | | | - Alan B. Leichtman
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Robert M. Merion
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
- Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | | | - Kayse Lee Maass
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA USA
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Maass KL, Smith AR, Tucker EL, Schapiro H, Cottrell SM, Gendron E, Hill-Callahan P, Gill SJ, Daskin MS, Merion RM, Leichtman AB. Comparison of patient and provider goals, expectations, and experiences following kidney transplantation. Patient Educ Couns 2019; 102:990-997. [PMID: 30591284 DOI: 10.1016/j.pec.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/08/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE This study examined whether kidney transplant recipients' post-transplant goals and expectations align with those as perceived by their healthcare providers. METHODS Post-transplant goals and expectations across four domains were assessed via a descriptive survey of healthcare providers (N=72) and kidney transplant recipients (N=476) at the University of Michigan from March 23 - October 1, 2015. Demographic and transplant-related data were collected via a retrospective review of medical records, and survey responses were compared using Chi-square tests, Wilcoxon two-sample tests, and logistic regression. RESULTS Patients expressed higher quality of life (mean Neuro-QOL T-score 60.2 vs. 52.7), were less likely to report that they were currently experiencing complications (11% vs. 24%), and anticipated their transplants to last longer (median 25 vs. 15 years) and to live longer (median 80 vs. 71 years) than providers expected for their typical patient. However, provider perceptions of patients' future ability to feel well, perform daily activities and work were significantly higher than those expressed by patients (all p<0.05). CONCLUSION Kidney transplant patient and provider expectations differ in significant ways. PRACTICE IMPLICATIONS Identified areas of discordance may provide opportunities for patients and providers to better evaluate treatment option tradeoffs in post-transplant clinical interactions.
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Affiliation(s)
- Kayse Lee Maass
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, USA; Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Abigail R Smith
- Department of Biostatistics, University of Michigan, Ann Arbor, USA; Arbor Research Collaborative for Health, Ann Arbor, USA
| | - Emily L Tucker
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Hannah Schapiro
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Sabrina M Cottrell
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Evelyn Gendron
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | | | | | - Mark S Daskin
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, USA; Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Alan B Leichtman
- Arbor Research Collaborative for Health, Ann Arbor, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, USA.
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Helmuth ME, Liu Q, Turenne MN, Park JM, Oguntimein M, Dutcher SK, Balkrishnan R, Sharma P, Zee J, Leichtman AB, Smith AR. Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States. Clin J Am Soc Nephrol 2019; 14:421-430. [PMID: 30819667 PMCID: PMC6419280 DOI: 10.2215/cjn.10590918] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period. RESULTS Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%). CONCLUSIONS The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.
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Affiliation(s)
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Marc N. Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeong M. Park
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Murewa Oguntimein
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Sarah K. Dutcher
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Rajesh Balkrishnan
- Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Smith AR, Goodrich NP, Beil CA, Liu Q, Merion RM, Gillespie BW, Zee J. Graphical representation of survival curves in the presence of time-dependent categorical covariates with application to liver transplantation. J Appl Stat 2018. [DOI: 10.1080/02664763.2018.1558187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | | | | | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Brenda W. Gillespie
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
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45
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Andreev VP, Liu G, Yang CC, Smith AR, Helmuth ME, Wiseman JB, Merion RM, Weinfurt KP, Cameron AP, Lai HH, Cella D, Gillespie BW, Helfand BT, Griffith JW, DeLancey JOL, Fraser MO, Clemens JQ, Kirkali Z. Symptom Based Clustering of Women in the LURN Observational Cohort Study. J Urol 2018; 200:1323-1331. [PMID: 29990467 PMCID: PMC6298822 DOI: 10.1016/j.juro.2018.06.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Women with lower urinary tract symptoms are often diagnosed based on a predefined symptom complex or a predominant symptom. There are many limitations to this paradigm as often patients present with multiple urinary symptoms which do not perfectly fit the preestablished diagnoses. We used cluster analysis to identify novel, symptom based subtypes of women with lower urinary tract symptoms. MATERIALS AND METHODS We analyzed baseline urinary symptom questionnaire data obtained from 545 care seeking female participants enrolled in the LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) Observational Cohort Study. Symptoms were measured with the LUTS (lower urinary tract symptoms) Tool and the AUA SI (American Urological Association Symptom Index), and analyzed using a probability based consensus clustering algorithm. RESULTS Four clusters were identified. The 138 women in cluster F1 did not report incontinence but experienced post-void dribbling, frequency and voiding symptoms. The 80 women in cluster F2 reported urgency incontinence as well as urgency and frequency but minimal voiding symptoms or stress incontinence. Cluster F3 included 244 women who reported all types of incontinence, urgency, frequency and mild voiding symptoms. The 83 women in cluster F4 reported all lower urinary tract symptoms at uniformly high levels. All but 2 of 44 LUTS Tool and 8 AUA SI questions significantly differed between at least 2 clusters (p <0.05). All clusters contained at least 1 member from each conventional group, including continence, and stress, urgency, mixed and other incontinence. CONCLUSIONS Women seeking care for lower urinary tract symptoms cluster into 4 distinct symptom groups which differ from conventional clinical diagnostic groups. Further validation is needed to determine whether management improves using this new classification.
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Affiliation(s)
| | - Gang Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | - H Henry Lai
- Washington University School of Medicine, St. Louis, Missouri
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago
| | | | | | | | | | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Lai HH, Helmuth ME, Smith AR, Wiseman JB, Gillespie BW, Kirkali Z. Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence Among Male and Female Patients Seeking Care for Their Lower Urinary Tract Symptoms. Urology 2018; 123:34-43. [PMID: 30393054 DOI: 10.1016/j.urology.2018.09.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/27/2018] [Accepted: 09/15/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To describe the relationship between metabolic factors and lower urinary tract symptoms, overactive bladder syndrome (OAB) and urinary incontinence (UI). METHODS Adult male and female patients who presented to a clinician from the symptoms of lower urinary tract dysfunction research network were recruited. Urinary symptoms (presence of OAB, any UI, stress UI (SUI), urgency UI (UUI), urgency, frequency, and nocturia) were assessed with the lower urinary tract symptoms tool. Metabolic factors assessed included central obesity (waist circumference, using the Adult Treatment Panel III, the International Diabetes Federation thresholds, and waist circumference as a continuous variable), general obesity (body mass index as dichotomous or continuous variables), diabetes mellitus, hypertension, and dyslipidemia. Multivariable logistic regression was used to test for associations. RESULTS 920 participants were studied. In multivariable analyses, central obesity (per 10 cm larger waist) was associated with higher odds of UI in both sexes (odds ratio [OR] = 1.16, P = .008), SUI in females (OR = 1.27, P = .008), UUI in both sexes (OR = 1.24, P = .001), OAB in females (OR = 1.248, P = .003), as well as frequency and nocturia. General obesity (5-unit increase in body mass index) was associated with UI, UUI, urgency and frequency in both sexes, and with SUI and OAB in females. We did not find associations between central or general obesity and OAB in males. Dyslipidemia was associated with nocturia ≥2. CONCLUSION In patients, central and general obesity were key metabolic factors associated with UI in both males and females, and with OAB in females but not in males. The association between dyslipidemia and nocturia ≥2 needs further research.
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Affiliation(s)
- H Henry Lai
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO.
| | | | | | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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47
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Butt Z, DiMartini AF, Liu Q, Simpson MA, Smith AR, Zee J, Gillespie BW, Holtzman S, Ladner D, Olthoff K, Fisher RA, Hafliger S, Freise CE, Mandell MS, Sherker AH, Dew MA. Fatigue, Pain, and Other Physical Symptoms of Living Liver Donors in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study. Liver Transpl 2018; 24:1221-1232. [PMID: 29698577 PMCID: PMC6153054 DOI: 10.1002/lt.25185] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/10/2018] [Indexed: 12/15/2022]
Abstract
Little is known about living liver donors' perceptions of their physical well-being following the procedure. We collected data on donor fatigue, pain, and other relevant physical outcomes as part of the prospective, multicenter Adult-to-Adult Living Donor Liver Transplantation Cohort Study consortium. A total of 271 (91%) of 297 eligible donors were interviewed at least once before donation and 3, 6, 12, and 24 months after donation using validated measures when available. Repeated measures regression models were used to identify potential predictors of worse physical outcomes. We found that donors reported more fatigue immediately after surgery that improved by 2 years after donation, but not to predonation levels. A similar pattern was seen across a number of other physical outcomes. Abdominal or back pain and interference from their pain were rated relatively low on average at all study points. However, 21% of donors did report clinically significant pain at some point during postdonation study follow-up. Across multiple outcomes, female donors, donors whose recipients died, donors with longer hospital stays after surgery, and those whose families discouraged donation were at risk for worse physical well-being outcomes. In conclusion, although not readily modifiable, we have identified risk factors that may help identify donors at risk for worse physical outcomes for targeted intervention. Liver Transplantation 00 000-000 2018 AASLD.
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Affiliation(s)
- Zeeshan Butt
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - Andrea F. DiMartini
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Mary Ann Simpson
- Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA
| | - Abigail R. Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Susan Holtzman
- Department of Psychology, University of British Columbia, Kelowna, BC
| | - Daniela Ladner
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robert A. Fisher
- Division of Transplantation, The Transplant Institute Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | | | - Chris E. Freise
- Departments of Medicine and Surgery, University of California at San Francisco, San Francisco, CA
| | | | - Averell H. Sherker
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
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48
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Liu Q, Smith AR, Park JM, Oguntimein M, Dutcher S, Bello G, Helmuth M, Turenne M, Balkrishnan R, Fava M, Beil CA, Saulles A, Goel S, Sharma P, Leichtman A, Zee J. The adoption of generic immunosuppressant medications in kidney, liver, and heart transplantation among recipients in Colorado or nationally with Medicare part D. Am J Transplant 2018; 18:1764-1773. [PMID: 29603899 PMCID: PMC6537862 DOI: 10.1111/ajt.14722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/25/2023]
Abstract
The transplant community is divided regarding whether substitution with generic immunosuppressants is appropriate for organ transplant recipients. We estimated the rate of uptake over time of generic immunosuppressants using US Medicare Part D Prescription Drug Event (PDE) and Colorado pharmacy claims (including both Part D and non-Part D) data from 2008 to 2013. Data from 26 070 kidney, 15 548 liver, and 6685 heart recipients from Part D, and 1138 kidney and 389 liver recipients from Colorado were analyzed. The proportions of patients with PDEs or claims for generic and brand-name tacrolimus or mycophenolate mofetil were calculated over time by transplanted organ and drug. Among Part D kidney, liver, and heart beneficiaries, the proportion dispensed generic tacrolimus reached 50%-56% at 1 year after first generic approval and 78%-81% by December 2013. The proportion dispensed generic mycophenolate mofetil reached 70%-73% at 1 year after generic market entry and 88%-90% by December 2013. There was wide interstate variability in generic uptake, with faster uptake in Colorado compared with most other states. Overall, generic substitution for tacrolimus and mycophenolate mofetil for organ transplant recipients increased rapidly following first availability, and utilization of generic immunosuppressants exceeded that of brand-name products within a year of market entry.
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Affiliation(s)
- Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Jeong M. Park
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | | | - Sarah Dutcher
- Food and Drug Administration, Silver Spring, MD, USA
| | - Ghalib Bello
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Melissa Fava
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Adam Saulles
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Sangeeta Goel
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Division of Gastroenterology, Ann Arbor, MI, USA
| | - Alan Leichtman
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
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49
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Smith AR, Zhu D, Goodrich NP, Merion RM, Schaubel DE. Estimating the effect of a rare time-dependent treatment on the recurrent event rate. Stat Med 2018; 37:1986-1996. [PMID: 29479838 PMCID: PMC5943190 DOI: 10.1002/sim.7626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/31/2017] [Accepted: 01/05/2018] [Indexed: 11/05/2022]
Abstract
In many observational studies, the objective is to estimate the effect of treatment or state-change on the recurrent event rate. If treatment is assigned after the start of follow-up, traditional methods (eg, adjustment for baseline-only covariates or fully conditional adjustment for time-dependent covariates) may give biased results. We propose a two-stage modeling approach using the method of sequential stratification to accurately estimate the effect of a time-dependent treatment on the recurrent event rate. At the first stage, we estimate the pretreatment recurrent event trajectory using a proportional rates model censored at the time of treatment. Prognostic scores are estimated from the linear predictor of this model and used to match treated patients to as yet untreated controls based on prognostic score at the time of treatment for the index patient. The final model is stratified on matched sets and compares the posttreatment recurrent event rate to the recurrent event rate of the matched controls. We demonstrate through simulation that bias due to dependent censoring is negligible, provided the treatment frequency is low, and we investigate a threshold at which correction for dependent censoring is needed. The method is applied to liver transplant (LT), where we estimate the effect of development of post-LT End Stage Renal Disease (ESRD) on rate of days hospitalized.
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Affiliation(s)
- Abigail R Smith
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, Michigan 48109-2029, USA
- Arbor Research Collaborative for Health, 340 E. Huron St, Suite 300, Ann Arbor, Michigan 48104, USA
| | - Danting Zhu
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, Michigan 48109-2029, USA
| | - Nathan P Goodrich
- Arbor Research Collaborative for Health, 340 E. Huron St, Suite 300, Ann Arbor, Michigan 48104, USA
| | - Robert M Merion
- Arbor Research Collaborative for Health, 340 E. Huron St, Suite 300, Ann Arbor, Michigan 48104, USA
| | - Douglas E Schaubel
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, Michigan 48109-2029, USA
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50
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Mukwege D, Peters L, Amisi C, Mukwege A, Smith AR, Miller JM. Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldijk classifications. Int J Gynaecol Obstet 2018; 142:187-193. [PMID: 29705989 DOI: 10.1002/ijgo.12514] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/13/2018] [Accepted: 04/26/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To derive a comprehensive system that allows a single score to define relative fistula severity. METHODS The present observational study included women with urogenital fistula treated at the Panzi Hospital, Democratic Republic of Congo, or its outreach clinics across the Democratic Republic of Congo between September 1, 2013, and December 31, 2014. Fistula severity was assessed by Goh and Waaldijk classifications and surgical success was ascertained. Logistic regression was used to select fistula characteristics predictive of surgical failure, and to preliminarily verify the newly derived Panzi score. RESULTS Overall, 837 women were included in the analysis. Goh or Waaldijk fistula descriptors associated with a higher probability of poor surgical outcomes in the unadjusted bivariate analysis were circumferential defect (P=0.007), proximity to the external urethral orifice (P=0.001), and size (P=0.001). These fistula characteristics were used to construct the Panzi score, which varied from 3 (most severe) to 0 (minor fistula). For each increase above 0, the odds of surgical failure increase by a factor of 1.65 (P<0.001). CONCLUSION The Panzi score of urogenital fistula provided a data-driven, simple, comprehensive, and parsimonious score. It could be used to report group data, to provide continuous level data for use in higher order statistics, and to resolve issues such as the cut-off point for referring women to hospital in accordance with fistula complexity.
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Affiliation(s)
- Denis Mukwege
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital Health System/Outreach Clinics, Bukavu, Democratic Republic of Congo.,International Center for Advanced Research and Training in Bukavu, Bukavu, Democratic Republic of Congo
| | - Lisa Peters
- International Center for Advanced Research and Training in Bukavu, Bukavu, Democratic Republic of Congo.,School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Christine Amisi
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital Health System/Outreach Clinics, Bukavu, Democratic Republic of Congo.,International Center for Advanced Research and Training in Bukavu, Bukavu, Democratic Republic of Congo
| | - Alain Mukwege
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | | | - Janis M Miller
- International Center for Advanced Research and Training in Bukavu, Bukavu, Democratic Republic of Congo.,School of Nursing, University of Michigan, Ann Arbor, MI, USA
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