The impact of obesity on vaginal hysterectomy and laparoscopically-assisted vaginal hysterectomy outcomes: A randomised control trial.

OBJECTIVES: This prospective randomised control trial aimed to compare outcome measures of vaginal hysterectomy (VH) and laparoscopically-assisted vaginal hysterectomy (LAVH) in obese vs. non-obese women undergoing hysterectomy for benign uterine conditions with a non-prolapsed uterus. The primary objective of the study was to estimate operation time, uterine weight and blood loss amongst obese and non-obese patients undergoing VH and LAVH. The secondary objective was to determine any difference in hospital stay, the need for post-operative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy for obese vs. non-obese patients undergoing VH and LAVH. STUDY DESIGN: A prospective randomised control study was undertaken in the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria set by the unit (vaginally accessible uterus, uterine size ≤ 12 weeks of gestation or ≤ 280gr on ultrasound examination, pathology confined to the uterus) were included in the study. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. All the LAVHs were performed by one surgeon (AC). In addition to the patient characteristics and surgical approach to hysterectomy, operative time, estimated blood loss, uterine weight, length of hospital stay, intra-operative and immediate post-operative complications were also recorded in obese and non-obese patient groups and comparatively analysed. RESULTS: A total of 227 women were included in the study. 151 patients underwent VH and 76 LAVH, upon randomisation on a 2:1 basis, reflecting the habitual proportion of hysterectomy cases in the Urogynaecology and Endoscopy Unit at CMJAH. No significant differences were found in mean shift of pre-operative to post-operative serum haemoglobin, uterine weight, intra- and immediate post-operative complications, and convalescence period when comparing obese and non-obese patients in both the VH and LAVH groups. There was a statistically significant difference in operating time between the two procedures. The LAVHs took longer compared to the VHs to be performed (62.8 ± 9.3 vs. 29.9 ± 6.6 min in non-obese patients, and 62.7 ± 9.8 vs 30.0 ± 6,9 min for obese patients). All VHs and LAVHs were successfully accomplished without major complications. CONCLUSION: VH and LAVH for the non-prolapsed uterus is a feasible and safe alternative for obese patients demonstrating similar perioperative outcome measures as non-obese women undergoing VH and LAVH. Where possible, VH should be preferred to LAVH as it is a safe route of hysterectomy, with operation time being significantly shorter.

Physical Function and Strength in Relation to Inflammation in Older Adults with Obesity and Increased Cardiometabolic Risk.

BACKGROUND: Inflammation is implicated in functional decline and the development of disability in aging. This study aimed to investigate the association of inflammation with physical function and muscle strength in older adults with obesity and increased cardiometabolic risk. DESIGN: In baseline assessments from the CROSSROADS randomized controlled trial, serum interleukin-6 (IL-6), tumor necrosis factor-α (TNFα) and C-reactive protein (hs-CRP) were assayed in 163 older adults (37% males, 24% African American, BMI 34±3, age 70±5yrs) with hypertension, dyslipidemia and/or diabetes. Physical function was assessed by six-minute walk test (6MWT), chair sit-and-reach (CSR), hand-grip and knee-extension strength; specific-strength as muscle strength/mass ratio. Analyses included ANCOVA and multiple linear regression adjusted for thigh skeletal muscle (MRI), arm lean mass (DXA) and moderate-to-vigorous intensity physical activity (MVPA; accelerometry). RESULTS: Higher hs-CRP (p<0.01) and IL-6 (p=0.07) were associated with lower 6MWT and CSR, respectively. A composite inflammation score combining all 3 inflammatory markers showed the strongest inverse association with 6MWT (p<0.01). MVPA moderated associations such that amongst participants who engaged in low MVPA, 6MWT distances and CSR scores were significantly lower in those with high IL-6 and TNFα (p<0.05), respectively. In participants with high MVPA, higher hs-CRP (p<0.05) and TNFα (p=0.07) were associated with poorer upper-extremity specific-strength. CONCLUSIONS: Chronic inflammation was associated with poorer physical function and specific strength in older adults with obesity and increased cardiometabolic risk. This association was strongest in participants with multiple elevated inflammatory markers. Physical activity levels below current recommendations mitigated the deleterious effects of inflammation on lower body mobility, underscoring the benefits of exercise for preserving physical function with age.

Associations between participation in family activities and adolescent school problems.

INTRODUCTION: Adolescent risk outcomes related to school issues are widespread, with about 20% parents reporting poor school engagement amongst their youth. Previous literature suggests that adolescents who report strong bonds with their parents are often identified as being less likely to engage in risky behaviours, such as substance use. The current study sought to examine the association between the frequencies of selected family activities and school problems amongst adolescents after adjustments for family connectedness and other characteristics. METHODS: Data were drawn from the National Longitudinal Survey of Youth, 1997. Of the 8984 youth interviewed, 3855 also had a sibling interviewed who met the selection criteria. School problem outcomes measured were suspension occurrence, poor grades and highest grade completed low for age. Independent variables of interest were self-reported frequency of family dinner, fun and religious activities in a typical week. Multivariable logistic models were estimated for each outcome, and multivariable linear probability models were estimated adjusting for family fixed effects. RESULTS: Adjusting for family connectedness, there were significant associations between certain family activities and adolescent school problem measures. However, these results did not remain significant in models with family fixed effects, suggesting that associations could be driven by family-level confounders. DISCUSSION: This study did not find strong evidence of a protective relationship between family activities and school problems. Therefore, it suggested that programme and policymakers be cautious in overstating the importance of family activities in preventing adolescent risk outcomes until true causal relationships can be determined.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture.

SUMMARY: This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound. INTRODUCTION: This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture. METHODS: This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics. RESULTS: States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056). CONCLUSIONS: Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Food behavior change in late-life widowhood: A two-stage process.

Widowhood is a common life event for married older women. Prior research has found disruptions in eating behaviors to be common among widows. Little is known about the process underlying these disruptions. The aim of this study was to generate a theoretical understanding of the changing food behaviors of older women during the transition of widowhood. Qualitative methods based on constructivist grounded theory guided by a critical realist worldview were used. Individual active interviews were conducted with 15 community-living women, aged 71-86 years, living alone, and widowed six months to 15 years at the time of the interview. Participants described a variety of educational backgrounds and levels of health, were mainly white and of Canadian or European descent, and reported sufficient income to meet their needs. The loss of regular shared meals initiated a two-stage process whereby women first fall into new patterns and then re-establish the personal food system, thus enabling women to redirect their food system from one that satisfied the couple to one that satisfied their personal food needs. Influences on the trajectory of the change process included the couple's food system, experience with nutritional care, food-related values, and food-related resources. Implications for research and practice are discussed.

Multimodal intervention to improve osteoporosis care in home health settings: results from a cluster randomized trial.

SUMMARY: We conducted a cluster randomized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care. The trial did not find a significant difference in medication use in the intervention arm. INTRODUCTION: This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures. METHODS: We conducted a cluster randomized trial of a multimodal intervention targeted at home care for high-risk patients (prior fracture or physician-diagnosed osteoporosis) receiving care in a statewide home health agency in Alabama. Offices throughout the state were randomized to receive the intervention or to usual care. The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications. A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis. Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications. A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre-post design. RESULTS: There were 11 offices randomized to each of the treatment and control arms; these offices treated 337 and 330 eligible patients, respectively. Among the offices in the intervention arm, the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 %, compared with 15.7 % in the usual care arm (difference in proportions 3.4 %, 95 % CI, -2.6 to 9.5 %). The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward, a nonsignificant difference. CONCLUSIONS: The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients.

Dietary patterns and diet quality among diverse older adults: the University of Alabama at Birmingham Study of Aging.

OBJECTIVES: To characterize dietary patterns among a diverse sample of older adults (≥ 65 years). DESIGN: Cross-sectional. SETTING: Five counties in west central Alabama. PARTICIPANTS: Community-dwelling Medicare beneficiaries (N=416; 76.8 ± 5.2 years, 56% female, 39% African American) in the University of Alabama at Birmingham (UAB) Study of Aging. MEASUREMENTS: Dietary data collected via three, unannounced 24-hour dietary recalls was used to identify dietary patterns. Foods were aggregated into 13 groups. Finite mixture modeling (FMM) was used to classify individuals into three dietary patterns. Differences across dietary patterns for nutrient intakes, sociodemographic, and anthropometric measurements were examined using chi-square and general linear models. RESULTS: Three dietary patterns were derived. A "more healthful" dietary pattern, with relatively higher intakes of fruit, vegetables, whole grains, eggs, nuts, legumes and dairy, was associated with lower energy density, higher quality diets as determined by healthy eating index (HEI)-2005 scores and higher intakes of fiber, folate, vitamins C and B6, calcium, iron, magnesium, and zinc. The "western-like" pattern was defined by an intake of starchy vegetables, refined grains, meats, fried poultry and fish, oils and fats and was associated with lower HEI-2005 scores. The "low produce, high sweets" pattern was characterized by high saturated fat, and low dietary fiber and vitamin C intakes. The strongest predictors of better diet quality were female gender and non-Hispanic white race. CONCLUSION: The dietary patterns identified may provide a useful basis on which to base dietary interventions targeted at older adults. Examination of nutrient intakes regardless of the dietary pattern suggests that older adults are not meeting nutrient recommendations and should continue to be encouraged to choose high quality diets.

Food choice among homebound older adults: motivations and perceived barriers.

OBJECTIVES: The purpose of this paper is to identify: motivations and perceived barriers associated with food choices made by homebound older adults; whether motivations and perceived barriers vary according to social demographic characteristics; and whether motivations and perceived barriers are associated with dietary quality. DESIGN: This was an observational study using standard interview methods where participants were administered a questionnaire and completed three 24-hour dietary recalls. SETTING: Participants were interviewed in their homes. PARTICIPANTS: 185 homebound older adults were included. MEASUREMENT: Motivations were assessed using a modification of The Food Choice Questionnaire and perceived barriers were assessed using the Vailas Food Enjoyment Questionnaire. Participants answered questions regarding social demographic characteristics. Dietary quality measures of adequate intakes of calories, protein, vitamin D, and vitamin B12 were obtained from the three 24-hour dietary recalls. RESULTS: Mean age was 78.9; 80% were female; and 36% were African American. Key motivations in food choice included sensory appeal, convenience, and price. Key barriers included health, being on a special diet, and being unable to shop. These varied little by social demographics, except for age. Dietary quality varied according to different motivations and barriers. CONCLUSION: Food choices are based upon a complex interaction between the social and environmental context, the individual, and the food. Efforts to change eating behaviors, especially community-based interventions involving self-management approaches, must carefully take into account individuals' self-perceived motivations and barriers to food selection. Incorporating foods that are tasty, easy to prepare, inexpensive, and that involve caregivers are critical for successful interventions.

Psychological improvements associated with behavioral and drug treatment of urge incontinence in older women.

The purpose of this study was to explore changes in psychological distress associated with behavioral treatment and drug treatment for urge incontinence in community-dwelling older women. Participants were 197 ambulatory, nondemented women (aged 55 years or older) with persistent urge urinary incontinence. Participants were patients in a randomized clinical trial comparing biofeedback-assisted behavioral treatment, drug treatment with oxybutynin chloride, and a placebo-control condition. Psychological distress was measured before and after treatment using the Hopkins Symptom Checklist (SCL-90-R). Multivariate and univariate analyses of variance showed that the two treatment groups and the control group had similar significant improvements on the nine subscales and the global severity index. Analysis of individual SCL-90-R subscale scores revealed trends suggesting that behavioral treatment tended to produce the largest improvements. The reductions of distress were not correlated consistently with reduction of incontinence. The results of this study showed that psychological distress was significantly reduced after treatment, regardless of the type of treatment.

Reliability assessment of the bladder diary for urinary incontinence in older women.

BACKGROUND: A reliable method of documenting the frequency of incontinent episodes is essential for assessment of treatment outcome in both clinical practice and research studies. Bladder diaries, completed prospectively by the patient, have been widely used for this purpose. This study investigated the number of consecutive days of bladder diary reports of incontinence frequency necessary to obtain adequate internal consistency (reliability). METHODS: Participants were 214 community-dwelling women, aged 40 to 90 years, with a history of stress, urge, or mixed urinary incontinence, persisting at least 3 months with a frequency of two or more episodes of urine leakage per week. Each participant kept a 14-day bladder diary documenting the time and circumstances of each incontinence episode. RESULTS: The mean age of participants was 63.5 years; 16.9% were African American. Women with predominantly urge incontinence (n = 138) reported a daily frequency of 2.1 incontinent episodes. Although there was a statistically significant difference between Week 1 (2.4 episodes per day) and Week 2 (2.0 episodes per day; p < .0001), five days were necessary to obtain an internal consistency of .90 for Cronbach's alpha. Women with predominantly stress incontinence (n = 76) had no statistical difference between Week 1 and Week 2 in frequency of incontinence, reporting an average 2.2 accidents per week in Week 1 and 2.1 in Week 2. However, 7 days of bladder diary were required before adequate internal consistency was reached. CONCLUSION: Seven consecutive days of bladder diary provides a stable and reliable measurement of the frequency of incontinence episodes in community-dwelling women.

Labelled monoclonal antibodies used for the detection of inflammatory processes and and bone marrow metastases.

This review gives a short history of the developments of immunoscintigraphy using radiolabelled monoclonal antibodies and will look at some clinical indications studied in close cooperation with international groups. Examples are presented of infected orthopaedic prostheses and the diagnosis of osteomyelitis in diabetic foot in which the method is considered diagnostically helpful. Furthermore, the accuracy of the bone marrow immunoscintigraphy is discussed in evaluating results of a multi-centre study, clearly demonstrating its diagnostic superiority over bone scanning in metastatic cancer. It is concluded that the future diagnostic trend is going towards more specific agents (antibodies, peptides) and a speedier availability of the diagnostic results in cases of supposed infection.

Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization.

The study was a clinical series of 95 ambulatory women with urinary incontinence. After voiding, each subject was scanned with a BladderScan BVI 2500, then catheterized for postvoid residual (PVR) and then scanned again. The mean PVR obtained by ultrasound was 49 ml, significantly larger than the mean PVR of 32 ml obtained by catheterization. Correlation analysis showed that the difference was not related to age, weight, body mass index, parity, pelvic prolapse or prior incontinence surgery, but was associated with prior hysterectomy and uterine prolapse. Regression analysis revealed that the difference was independently related to prior hysterectomy only. Postcatheterization ultrasound detected a mean of 22 ml, suggesting that the difference between the PVR values may be due to residual urine not removed by catheterization. Finally, ultrasound had a sensitivity of 66.7% and a specificity of 96.5% in detecting PVR > or = 100 ml. Portable ultrasound scanners are quick, easy to use, reasonably sensitive, and very specific for determining elevated PVR.

Combined behavioral and drug therapy for urge incontinence in older women.

OBJECTIVE: The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community-dwelling older women. DESIGN: Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy. SETTING: A university-based outpatient geriatric medicine clinic. PARTICIPANTS: Subjects in the clinical trial were 197 ambulatory, nondemented, community-dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty-five subjects participated in combined treatment. INTERVENTION: One group of subjects received four sessions (over 8 weeks) of biofeedback-assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training. MEASUREMENTS: Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes. RESULTS: Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty-seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001). CONCLUSIONS: This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.

Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.

CONTEXT: Urinary incontinence is a common condition caused by many factors with several treatment options. OBJECTIVE: To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women. DESIGN: Randomized placebo-controlled trial conducted from 1989 to 1995. SETTING: University-based outpatient geriatric medicine clinic. PATIENTS: A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia. INTERVENTION: Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. MAIN OUTCOME MEASURES: Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment. RESULTS: For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups. CONCLUSION: Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.

Nutritional status of urban homebound older adults.

The purposes of this study were to assess comprehensively the nutritional status of frail older adults living in an urban area and to identify factors associated with nutritional insufficiency. Subjects were 49 adults aged > or = 65 y followed by the Jefferson County Home Health Department. Twenty-nine percent of the women and 63% of the men had a body mass index (BMI; in kg/m2) < 24. Nineteen percent had serum albumin concentrations < 35 g/L (3.5 g/dL). More than one-half of the subjects reported symptoms of oral health problems. The key dependent variables were serum albumin concentration and BMI. In univariate analyses, a lower BMI correlated with oral symptoms, male sex, increased age, and less education. Lower serum albumin concentrations were associated with advanced age, increased dependence in Activities of Daily Living (ADL), oral symptoms, and presence of a caregiver. A stepwise multiple-regression model for BMI and serum albumin showed that predictors of low BMI were increased age, less education, difficulty in chewing, and absence of dentures. Variables in the model for lower serum albumin concentrations were sex, increased age, increased dependence in ADLs, and wearing of dentures. In a secondary analysis that controlled for age, education level, functional status, and sex, oral symptoms remained associated with lower BMI but not with lower serum albumin concentrations. This study found a high prevalence of undernutrition in urban homebound older adults and suggests that oral health disability may affect nutritional status in this population.

Monitoring systemic venous oxygen saturations in the hypoplastic left heart syndrome.

Although progress has been made in treating hypoplastic left heart syndrome, improvements in perioperative care may further decrease mortality. We present a case in which continuous monitoring of systemic venous oxygen saturation allowed stabilization and successful management of a critically ill infant. Systemic venous oxygen saturation may provide a more accurate representation of a child's clinical status, allowing more rapid intervention and better outcomes.

Quantitative evaluation of manganese-52m as a myocardial perfusion tracer in pigs using positron emission tomography.

There is a need for a quantitative myocardial perfusion agent that does not require an on-site cyclotron. Early studies with manganese demonstrated that this trace metal is of potential use for myocardial imaging. 52mMn can be produced in a 52Fe-52mMn generator and is suitable for positron emission tomographic (PET) imaging. The purpose of this study was to evaluate 52mMn with regard to its potential to quantitatively assess myocardial perfusion. Dynamic PET imaging was performed in six pigs with various doses of dipyridamole to increase blood flow. Retention (R) and model-based K1 values were correlated with microsphere blood flow. The models consisted of one (K1, k2) and two (K1, k2, k3) tissue compartments. Anterior, lateral and septal regions showed a good myocardium-to-background ratio; the evaluation of the inferior wall was impaired by high liver uptake. Linear regression yielded the following equations: K1=1.152 flow+0.059 (r=0.92), R=0.069 flow+0.034 (r=0.84). Based on these regressions, K1 increased 2.7-fold and R 2.6-fold in the examined flow range of 0.5-2 ml/min/g (fourfold increase), demonstrating an underestimation of higher flow rates by both measures. It is concluded that 52mMn allows the qualitative assessment of myocardial perfusion but does not meet the requirements of a quantitative myocardial perfusion agent.

Nocturnal enuresis in community-dwelling older adults.

OBJECTIVE: To investigate the prevalence and characteristics of nocturnal enuresis in community-dwelling older adults and to identify potential predisposing variables. DESIGN: Interview survey. SETTING: Five rural counties in northwestern Pennsylvania. PARTICIPANTS: Subjects were 3884 community-dwelling older adults aged 65 to 79 years who volunteered for a health promotion demonstration. MEASUREMENTS: The dependent variable was self-reported accidental loss of urine during sleep. Independent variables included demographic variables, self-reported disease history and symptomatology, and standardized screening instruments for depression (CES-D), dementia (MMSE), and functional status (ADLs). MAIN RESULTS: Prevalence of nocturnal enuresis was 2.1%, and was significantly higher among women (2.9%) compared with men (1.0%; P < .0001). Compared with subjects with daytime incontinence only, those with nocturnal enuresis reported greater severity and impact of incontinence on several parameters. Enuretics were more likely to have received treatment; treatment outcome, however, was significantly less successful. In univariate analyses, enuresis was significantly associated with symptoms of congestive heart failure (CHF), impairment in activities of daily living, depression, and use of sleep medications at least once per week. In stepwise logistic regression modeling, two symptoms of congestive heart failure and regular use of sleep medication entered the model. CONCLUSIONS: Nocturnal enuresis appears to be uncommon among older adults, but it may be associated with poorer therapeutic outcomes compared with the more common forms of daytime incontinence. The findings are consistent with the hypothesis that daytime fluid accumulation followed at night by mobilization of excess fluid is a contributor to enuresis in older adults.

Education of staff and students in health care settings: integrating practice and research.

A cooperative program between the University of Iowa Hospitals and Clinics (UIHC) Department of Social Service (DSS) and the University of Iowa School of Social Work (UISSW) integrates faculty and students with clinicians for both practice and/or research internships. This program has endeavored to enhance practice and research social work through the development of (1) multiple student training programs offering both practice and research placement opportunities, (2) a jointly appointed faculty position between the UISSW and the UIHC DSS designed to improve researchers' access to and involvement with practice and practitioners' involvement in practice research, and (3) specialized student training programs including research projects in practice specialties. This project has helped clinicians conduct research, provided students with practical research experience within a clinical setting, and has increased the likelihood that both staff and students will participate in research.