Urinary and fecal incontinence are independently associated with falls risk among older women and men with complex needs: A national population study.

AIMS: To determine the relationships between urinary incontinence (UI), fecal incontinence (FI), and falls risk among community-dwelling older women and men with complex needs, after controlling for confounders. METHODS: All community care recipients in New Zealand undergo standardized needs assessments, using the Home Care International Residential Assessment Instrument (interRAI-HC), which elicits information over multiple domains, including UI and FI frequency and falls. Consenting women and men aged greater than or equal to 65 years with at least one interRAI-HC assessment undertaken between 1 July 2012 and 1 June 2018 were investigated using multilevel mixed effects ordinal regression models, stratified by sex. RESULTS: Overall, 57 781 (61.8%) women and 35 681 (38.2%) men were eligible, contributing 138 302 interRAI-HC assessments. At first assessment, the average age was 82.0 years (range: 65-109 years); high falls risk was common, found among 8.8% of women and 12.4% of men; and 43.7% of women and 33.7% of men reported some incontinence. For women, the adjusted odds of increasing falls risk was 1.24 (95% CI: 1.18, 1.30) for those with occasional UI, 1.36 (95% CI: 1.29, 1.43) for those with frequent UI, and 1.19 (95% CI: 1.13, 1.26) for those with any FI compared with their continent counterparts. Among men, the adjusted odds were 1.49 (95% CI: 1.41, 1.58) for any UI and 1.18 (95% CI: 1.10, 1.27) for any FI. CONCLUSION: UI and FI are common, have separate associations with falls risk among women and men, and would benefit from routine screening in primary health care for older adults.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction.

INTRODUCTION: In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report. METHODS: This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text. CONCLUSIONS: A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Special considerations in the urological management of the older spinal cord injury patient.

PURPOSE: This paper reports the key findings of Committee 8 of the Joint SIU-ICUD Consultation on Urologic Management of the Spinal Cord Injured Patient and address issues pertaining to the older person with a SCI and the time-related changes relevant to their urological, gastrointestinal and functional management. METHODS: A literature review using the Pubmed and Ovid search engines was performed examining pertinent literature regarding SCI in the older patient. RESULTS: There is a rising incidence of both traumatic and non-traumatic spinal cord injury (SCI) in older people and improvements in healthcare and nutrition mean patients with SCI are living longer. Outcomes after a SCI in the older person are a sum of the effects of injury and its management compounded by specific effects of ageing and the emergence of unrelated comorbidities. Changes in health, comorbidities, cognition and dexterity with ageing have an impact on function and are important considerations in the management of the older patient with SCI. Treatment decisions are thus increasingly complex due to the need to take into account these changes and accompanying polypharmacy. For the person living with a SCI, changes in circumstances (social and financial) have an impact on quality of life and influence management and support strategies. CONCLUSIONS: Older patients with SCI face additional challenges both in the acute setting and with ageing. Clinicians should take into account comorbid conditions, mental health, physical function, cognition and social support in making management decisions. With the global ageing population, health services planning will need to allow for increase in resources required to care for older patients with SCI.

Symptoms of bowel dysfunction and their management after spinal cord injury in a New Zealand centre.

AIM: To document the symptoms of bowel dysfunction, and how the bowels are managed, in a cohort of patients following a spinal cord injury. To relate these to the level of the spinal injury and to examine the relationship between bowel symptoms and bladder dysfunction. METHOD: Participants were identified from the discharge data from the Burwood Spinal Unit, one of two national Spinal Units in New Zealand, in two two-year sets from 1-3 years post-injury and from 20-21 years post-injury. With informed consent, they completed a survey developed for symptoms and management using Survey Monkey. This was cross-related to the level of cord injury and the AIS Scale, and then to the latest urodynamic analysis. RESULTS: A total of 54 patients were included; data was incomplete in five patients. No specific relation was found between bowel sensation, bowel continence, bowel management, nor with bladder function. CONCLUSION: Lack of correlation of patterns of bowel function with the level and severity of the cord lesion indicates the need to continue to individualise advice on bowel care according to symptoms.

Diversity, distribution and conservation of the terrestrial reptiles of Oman (Sauropsida, Squamata).

In the present work, we use an exceptional database including 5,359 records of 101 species of Oman's terrestrial reptiles together with spatial tools to infer the spatial patterns of species richness and endemicity, to infer the habitat preference of each species and to better define conservation priorities, with especial focus on the effectiveness of the protected areas in preserving this unique arid fauna. Our results indicate that the sampling effort is not only remarkable from a taxonomic point of view, with multiple observations for most species, but also for the spatial coverage achieved. The observations are distributed almost continuously across the two-dimensional climatic space of Oman defined by the mean annual temperature and the total annual precipitation and across the Principal Component Analysis (PCA) of the multivariate climatic space and are well represented within 17 out of the 20 climatic clusters grouping 10% of the explained climatic variance defined by PC1 and PC2. Species richness is highest in the Hajar and Dhofar Mountains, two of the most biodiverse areas of the Arabian Peninsula, and endemic species richness is greatest in the Jebel Akhdar, the highest part of the Hajar Mountains. Oman's 22 protected areas cover only 3.91% of the country, including within their limits 63.37% of terrestrial reptiles and 50% of all endemics. Our analyses show that large areas of the climatic space of Oman lie outside protected areas and that seven of the 20 climatic clusters are not protected at all. The results of the gap analysis indicate that most of the species are below the conservation target of 17% or even the less restrictive 12% of their total area within a protected area in order to be considered adequately protected. Therefore, an evaluation of the coverage of the current network of protected areas and the identification of priority protected areas for reptiles using reserve design algorithms are urgently needed. Our study also shows that more than half of the species are still pending of a definitive evaluation by the International Union for Conservation of Nature (IUCN).

Falls and hip fractures associated with urinary incontinence among older men and women with complex needs: A national population study.

AIMS: To determine if urinary incontinence (UI) was an independent risk factor for falls and hip fractures in community-dwelling older men and women with complex needs, after controlling for confounders. METHODS: Since 2012, all community care recipients in New Zealand have undergone standardized needs assessments using the Home Care International Residential Assessment Instrument (interRAI-HC). The interRAI-HC elicits information over multiple domains, including UI frequency and falls. Those aged 65+ years with assessment between July 1, 2012 and May 31, 2014 without collection devices or indwelling catheters were matched to hospital, mortality, and pharmaceutical databases, and apposite regression models applied. RESULTS: Overall, 25 257 (37.5%) men and 42 032 (62.5%) women were eligible, with average age of 82.7 years (range: 65, 106 years). Incontinence was reported by 34.3% of men and 42.6% of women, falls within 90 days by 42.7% of men and 39.1% of women; and fractures recorded for 2.5% of men and 3.7% of women. In multivariable analysis, UI was significantly associated with falls (P < 0.001), and differentially related by sex (P < 0.001). Compared to continent participants, the odds of increasing falls risk was 1.69 (95% CI: 1.57, 1.82) for men with frequent incontinence and 1.53 (95% CI: 1.43, 1.64) for men with occasional continence; higher than the 1.39 (95% CI: 1.32, 1.46) and 1.33 (95% CI: 1.26, 1.39), respectively, for women. UI was not associated with hip fractures. CONCLUSION: UI is a common independent risk factor for falls but not hip fractures. Patterns are different between men and women with complex needs.

Urinary incontinence, but not fecal incontinence, is a risk factor for admission to aged residential care of older persons in New Zealand.

AIMS: To determine if urinary incontinence (UI) and fecal incontinence (FI) were independent risk factors for aged resident care (ARC) admissions for older people, after controlling for confounders and applying apposite statistical methods. METHODS: Since 2012, all community care recipients in New Zealand have undergone a standardized needs assessment using the Home Care International Residential Assessment Instrument (interRAI-HC). The interRAI-HC instrument elicits information on 236 questions over 20 domains, including UI and FI frequency within the last 3 days. Those aged 65+ years with an interRAI-HC assessment between July 1, 2012 and May 31, 2014 were matched to national mortality and ARC databases, and competing-risk regression models applied to those without collection devices or indwelling catheters who were admitted to ARC or alive 30+ days after their interRAI-HC assessment. RESULTS: Overall, 32 285 people were eligible, with average age of 82.1 years (range 65, 105 years) of whom 20 627 (63.9%) were female. UI and FI was reported by 36.4% and 12.9% of people, respectively. By June 30, 2014, 5993 (18.6%) had an ARC admission and 5443 (16.9%) had died before any such admission. In the multivariable analysis, the subhazard ratio (SHR) for ARC admission was significant for UI (SHR = 1.11, 95%CI: 1.05, 1.18) but not for FI (SHR = 1.07, 95%CI: 0.99, 1.16). CONCLUSIONS: UI is a common, independent risk factor for ARC admissions. Identifying the extent of incontinence and its impact on ARC admissions is the first vital step in addressing the burgeoning need for better community continence services.

Conservative treatment for incontinence in women in rest home care in Christchurch: Outcomes and cost.

AIMS: To assess if conservative therapy can reduce urinary leakage and pad usage and improve quality of life in elderly incontinent women living in a rest home setting; and if so at what additional cost. METHODS: Sixty-eight elderly women with urinary incontinence, and preserved cognitive ability, living in 26 rest homes were identified. Clinical evaluation, included bladder diary, pad weigh tests, pad usage, and quality of life and activities questionnaires (FIM: Functional Impairment Measure; EQ-5D: Euroquol 5 dimension score; ICIQ-SF: International Consultation on Incontinence-Short Form). A specialist Continence Advisor Nurse provided conservative treatment according to the needs of each participant. Outcomes were recorded after 12 weeks of treatment by repeating above evaluations, and the costs involved were measured. RESULTS: Leakage was reduced by a mean of 60 ml per 24 hr, and four fewer pads were required per week. The ICIQ-SF improved significantly. The EQ-5D did not demonstrate significant improvement, so a cost-utility analysis was not possible. The mean cost of the Advisor's time and mileage in providing the 12 week course was $247.75 per participant. CONCLUSION: Conservative therapies tailored to each individual, can improve the severity of leakage in the short term, even in this elderly group of women with preserved cognitive function, at modest additional cost. Measuring quality of life and the impact of incontinence, has challenges in this age group. Neurourol. Urodynam. 35:636-641, 2016. © 2015 Wiley Periodicals, Inc.

Workforce and Leader Development: Learning From the Baldrige Winners in Health Care.

It is ironic that perhaps the only constant in health care organizations today is change. To compete successfully in health care and position an organization for high performance amid continuous change, it is very important for managers to have knowledge of the best learning and development practices of high-performing organizations in their industry. The rapid increases in the rate of technological change and geometric increases in knowledge make it virtually imperative that human resources are developed effectively. This article discusses the best learning and development practices among the Malcolm Baldrige National Quality Award winners in the health care industry since 2002 when the industry had its first award-winning organization.

Performance management excellence among the Malcolm Baldrige National Quality Award Winners in Health Care.

When carefully constructed, performance management systems can help health care organizations direct their efforts toward strategic goals, high performance, and continuous improvement needed to ensure high-quality patient care and cost control. The effective management of performance is an integral component in hospital and health care systems that are recognized for excellence by the Malcolm Baldrige National Quality Award in Health Care. Using the framework in the 2011-2012 Health Care Criteria for Performance Excellence, this article identifies the best practices in performance management demonstrated by 15 Baldrige recipients. The results show that all of the recipients base their performance management systems on strategic goals, outcomes, or competencies that cascade from the organizational to the individual level. At the individual level, each hospital or health system reinforces the strategic direction with performance evaluations of leaders and employees, including the governing board, based on key outcomes and competencies. Leader evaluations consistently include feedback from internal and external stakeholders, creating a culture of information sharing and performance improvement. The hospitals or health care systems also align their reward systems to promote high performance by emphasizing merit and recognition for contributions. Best practices can provide a guide for leaders in other health systems in developing high-performance work systems.

Improving organizational climate for excellence in patient care.

Managers in health care organizations today are expected to achieve higher-quality patient care at a lower cost. Developing and maintaining a positive organizational climate can help improve motivation and foster higher employee performance. In turn, this will help the organization deliver better patient care at a lower cost. This article offers metrics for assessing organizational climate, analyzes barriers to a positive climate, and explores strategies that managers can use to build the type of climate that fosters high performance.

Conquering the Sahara and Arabian deserts: systematics and biogeography of Stenodactylus geckos (Reptilia: Gekkonidae).

BACKGROUND: The evolutionary history of the biota of North Africa and Arabia is inextricably tied to the complex geological and climatic evolution that gave rise to the prevalent deserts of these areas. Reptiles constitute an exemplary group in the study of the arid environments with numerous well-adapted members, while recent studies using reptiles as models have unveiled interesting biogeographical and diversification patterns. In this study, we include 207 specimens belonging to all 12 recognized species of the genus Stenodactylus. Molecular phylogenies inferred using two mitochondrial (12S rRNA and 16S rRNA) and two nuclear (c-mos and RAG-2) markers are employed to obtain a robust time-calibrated phylogeny, as the base to investigate the inter- and intraspecific relationships and to elucidate the biogeographical history of Stenodactylus, a genus with a large distribution range including the arid and hyper-arid areas of North Africa and Arabia. RESULTS: The phylogenetic analyses of molecular data reveal the existence of three major clades within the genus Stenodactylus, which is supported by previous studies based on morphology. Estimated divergence times between clades and sub-clades are shown to correlate with major geological events of the region, the most important of which is the opening of the Red Sea, while climatic instability in the Miocene is hypothesized to have triggered diversification. High genetic variability is observed in some species, suggesting the existence of some undescribed species. The S. petrii - S. stenurus species complex is in need of a thorough taxonomic revision. New data is presented on the distribution of the sister species S. sthenodactylus and S. mauritanicus. CONCLUSIONS: The phylogenetic hypothesis for the genus Stenodactylus presented in this work permits the reconstruction of the biogeographical history of these common desert dwellers and confirms the importance of the opening of the Red Sea and the climatic oscillations of the Miocene as major factors in the diversification of the biota of North Africa and Arabia. Moreover, this study traces the evolution of this widely distributed and highly specialized group, investigates the patterns of its high intraspecific diversity and elucidates its systematics.

Managing human resources for successful strategy execution.

Managers face difficult challenges when they implement organizational strategies to achieve important goals. Execution of strategy has become more dependent upon the effective management of human resources. This article suggests how people can be managed more effectively to facilitate the execution of strategies and improve organizational performance.

Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults.

BACKGROUND: The neural control of storage and voiding of urine is complex and dysfunction can be difficult to treat. One treatment for people with refractory symptoms is continuous electrical nerve stimulation of the sacral nerve roots using implanted electrodes and an implanted pulse generator. OBJECTIVES: To determine the effects of implantable electrical stimulation devices in the treatment of urine storage and voiding problems. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 10 February 2009), CENTRAL (The Cochrane Library 2008, Issue 1), MEDLINE (January 1980 to March 2008), EMBASE (January 1980 to March 2008), CINAHL (January 1982 to March 2008) and the reference lists of relevant articles. SELECTION CRITERIA: Trials that tested implanted electronic stimulators connected to electrodes attached to the nerves and providing continuous electrical stimulation for neuromodulation. DATA COLLECTION AND ANALYSIS: Both authors selected studies, assessed quality, and extracted data. MAIN RESULTS: Eight reports of randomised studies that evaluated implants which provided continuous stimulation were included. It was unclear whether some reports included patients who also appeared in other reports, so no data were pooled. In spite of this, it seems clear that continuous stimulation offers benefits for carefully selected people with overactive bladder syndrome and for those with urinary retention but no structural obstruction.Many of the implants did not work and many required revision operations. Many questions remain about patient selection and the best way to use these devices. AUTHORS' CONCLUSIONS: In spite of methodological problems, it would appear that some people benefit from implants which provide continuous nerve stimulation. More research is needed on the best way to improve patient selection, carry out the implant, and to find why so many fail. The effectiveness of implants should be tested against other interventions, particularly in people with an overactive bladder.

Managing immature, irresponsible, or irritating employees.

Most managers can remember employees who were immature, irresponsible, or very irritating. They also recall how difficult it was to direct these individuals. This article discusses attitudinal problems and counterproductive behavior that can lead to lower quality performance. The consequences of these actions for the organization, managers, coworkers, and patients are examined. A variety of managerial approaches for solving these problems are considered.

Inappropriate selection of first-line managers can be hazardous to the health of organizations.

Inappropriate selection decisions that occur when individuals are hired or promoted into first-line managerial positions without full consideration of their qualifications can create major problems for health care organizations. This article examines the perceptions that employees may have regarding new managers who are ineffective and the problems resulting from inappropriate selection decisions and offers suggestions for avoiding these problems.

Chronic suprapubic catheterization in the management of patients with spinal cord injuries: analysis of upper and lower urinary tract complications.

OBJECTIVE: To assess whether chronic suprapubic catheterization (SPC) in patients with spinal cord injury (SCI) is associated with a higher incidence of significant urinary tract complications than in patients whose urinary tracts are managed by other methods. PATIENTS AND METHODS: Our experience suggested that the incidence of complications in patients with SCI and SPC was acceptable and relatively low. Between 1988 and 2001, 1018 patients were admitted to our unit after SCI; 149 were managed by SPC and we retrospectively reviewed them, with a mean follow-up of 6 years. There were no complications in 49% of patients. Most complications were minor (urinary tract infection 27%, bladder stones 22%) and were easily managed. Only 20 patients had upper tract complications. Nine patients had renal scarring and 14, all quadriplegic, had upper tract calculi. One patient developed well-differentiated superficial transitional cell bladder cancer. CONCLUSIONS: Patients with SCI often prefer SPC than other methods offered to them, because of quality-of-life issues. The incidence of significant complications might not be as high as previously reported, and with a commitment to careful follow-up, SPC can be a safe option for carefully selected patients if adequate surveillance can be ensured.

The department manager and effective human resource planning: an overview.

Department managers in health care organizations play a pivotal role in ensuring the success of human resource (HR) planning. This article describes HR planning and its importance to the organization and department managers. Organizational support necessary for effective HR planning is also covered. The HR planning process is examined. Managerial responsibilities such as interviewing and performance appraisal and their relationship to HR planning are discussed.

A successful nurse-led model in the elective orthopaedic admissions process.

AIM: To document a nurse-led admissions process for same day orthopaedic surgery, on relatively fit patients under 70 years of age. METHODS: Patients undergoing minor surgery, under 70 years of age, and with a body mass index (BMI) of <35, were selected from the total of patients being admitted for elective orthopaedic surgery under the Accident Compensation Commission (ACC) contract. The nurse-led project relied primarily on an admission questionnaire, on physician consultation notes, and on previous clinical records. RESULTS: During the 6-month study, 331 patients with a median age of 38 years were categorised into 3 streams. 252 patients (76%) underwent a nursing-admission process without the need for further consultation with a junior medical officer or an anaesthetist. The remaining patients not included in the study were admitted and clerked by a house officer. No safety issues arose and the surgeons and anaesthetists were satisfied with the process. The junior medical officers described improved job satisfaction by being able to attend theatre, other educational opportunities, and working more closely with the consultant. SUMMARY: The process was safe; it improved the patient journey and job satisfaction among house surgeons; and it extended the skill base and job satisfaction of the nurses. It also allowed the hospital to cope better with the reduced number of house surgeons available. The process has now been incorporated into elective orthopaedic admissions at Burwood Hospital.

Propiverine compared to oxybutynin in neurogenic detrusor overactivity--results of a randomized, double-blind, multicenter clinical study.

OBJECTIVES: To compare the efficacy and tolerability of propiverine and oxybutynin in patients with neurogenic detrusor overactivity. METHODS: Patients were eligible, if at least 18 years of age and suffering from neurogenic detrusor overactivity. Eligibility also required a maximum cystometric capacity less than 300 ml. After a one-week run-in period, propiverine 15 mg t.i.d. or oxybutynin 5mg t.i.d. were administered for 21 days. As primary efficacy outcomes urodynamic parameters were assessed. As tolerability outcome the percentage of patients with newly manifesting anticholinergic adverse events was taken. RESULTS: 131 patients were recruited at 20 study centers. The maximum cystometric capacity (ml) was increased significantly in the propiverine group from 198 (+/-110) to 309 (+/-166), and in the oxybutynin group from 164 (+/-64) to 298 (+/-125). Similarly, maximum detrusor pressure during the filling phase (cm H(2)O) was lowered significantly in the propiverine group from 56.8 (+/-36.2) to 37.8 (+/-31.6), and in the oxybutynin group from 68.6 (+/-34.5) to 43.1 (+/-29.2). No significant differences resulted between treatment groups. Anticholinergic adverse events were reported less frequently in the propiverine compared to the oxybutynin group (63.0% versus 77.8%). Dryness of the mouth, the most frequent adverse event, was reported significantly less (47.1% versus 67.2%; p=0.02) in the propiverine compared to the oxybutynin group. CONCLUSION: Propiverine and oxybutynin are equally effective in increasing bladder capacity and lowering bladder pressure in patients with neurogenic detrusor overactivity. The trend for better tolerability of propiverine compared to oxybutynin achieved significance for dryness of the mouth.