The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function.

AIM: Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. METHOD: A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. RESULTS: There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. CONCLUSION: The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.

A new measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR).

INTRODUCTION AND HYPOTHESIS: The objective of this study was to create a valid, reliable, and responsive sexual function measure in women with pelvic floor disorders (PFDs) for both sexually active (SA) and inactive (NSA) women. METHODS: Expert review identified concept gaps and generated items evaluated with cognitive interviews. Women underwent Pelvic Organ Prolapse Quantification (POPQ) exams and completed the Incontinence Severity Index (ISI), a prolapse question from the Epidemiology of Prolapse and Incontinence Questionnaire (ISI scores), the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Female Sexual Function Index (FSFI). Principle components and orthogonal varimax rotation and principle factor analysis with oblique rotation identified item grouping. Cronbach's alpha measured internal consistency. Factor correlations evaluated criterion validation. Change scores compared to change scores in other measures evaluated responsiveness among women who underwent surgery. RESULTS: A total of 589 women gave baseline data, 200 returned surveys after treatment, and 147 provided test-retest data. For SA women, 3 subscales each in 2 domains (21 items) and for NSA women 2 subscales in each of 2 domains (12 items) emerged with robust psychometric properties. Cronbach's alpha ranged from .63 to .91. For SA women, correlations were in the anticipated direction with PFDI-20, ISI, and FSFI scores, POPQ, and EPIQ question #35 (all p < .05). PFDI-20, ISI, and FSFI subscale change scores correlated with Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire International Urogynecological Association-revised (PISQ-IR) factor change scores and with mean change scores in women who underwent surgery (all p < .05). For NSA women, PISQ-IR scores correlated with PFDI-20, ISI scores, and with EPIQ question #35 (all p < .05). No items demonstrated differences between test and retest (all p ≥ .05), indicating stability over time. CONCLUSIONS: The PISQ-IR is a valid, reliable, and responsive measure of sexual function.

FLQAI - A Questionnaire on Quality of Life in Fecal Incontinence: German translation and validation of Rockwood et al.'s (2000) Fecal Incontinence Quality of Life Scale (FIQLS).

AIM: The aim of the study was to produce a German version (FLQAI) of the Fecal Incontinence Quality of Life Scale (FIQLS) by Rockwood et al., an English-language measure of quality of life in fecal incontinence 1. The FIQLS has 29 items assigned to the four subscales of lifestyle, coping/behavior, depression/self-perception and embarrassment. MATERIAL AND METHODS: The FIQLS 1 was translated into German and adapted. Indicators of test quality (convergent and discriminant validity, reliability, confirmatory factor analysis) were determined in N = 88 subjects (mean age = 71.5 years) with fecal incontinence and urinary incontinence (control group, n = 29). RESULTS: Three of the four scales of the FLQAI had an acceptable internal reliability. The scales of the FLQAI showed significant correlations with selected subscales of the SF-36 2, the ADS 3 and the FISI 4 (convergent validity). Two of the four scales of the FLQAI discriminated between patients with fecal incontinence and patients with urinary incontinence (discriminant validity). The confirmatory factor analysis did not reveal a uniform fit of the data obtained with the German version with the original four-factor solution of the original version of the questionnaire. DISCUSSION: The Questionnaire on Quality of Life in Fecal Incontinence (FLQAI) is a German-language self-rating questionnaire with satisfactory psychometric properties for measuring disease-specific quality of life in elderly patients with fecal incontinence.

Faecal incontinence in men.

AIM: A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life. METHOD: Prospectively recorded data on 85 consecutive male patients evaluated for FI at our pelvic floor centre in 2004 and 2005 were reviewed and compared with a cohort of 408 female patients. Treatment outcome in men was assessed by questionnaire. RESULTS: The aetiology of FI could be determined in 61 (72%) men and was most commonly related to anal surgery (n = 23), prostate cancer therapy (n = 9) and spinal injury (n = 9). Eight patients had idiopathic soiling only. Mean age, Fecal Incontinence Severity Index (FISI) and quality of life scores were similar between men and women. Maximal mean resting pressure (MRP) and squeeze pressure (MSP) were on average higher in men than in women [MRP 56.9 (26.2) vs 40 (20.4) mmHg; P < 0.0001]; [MSP 98.1 (67.3) vs 39.4 (28.5) mmHg; P < 0.0001]. Sphincter defects involved the external sphincter less often in men (35 vs 70%, P = 0.004). Differences in faecal incontinence quality of life (FIQL) and SF-36 scores between men and women were minimal. After a median follow up of 2 years, complete resolution of symptoms was reported in 17% and improvement of symptoms in another 48% of men. CONCLUSION: Although physiological and anatomical features of FI differ between men and women, its severity and impact on quality of life are similar. External sphincter defects are less common in men; hence, direct sphincter repair is less frequently an option. Evaluation and treatment improves symptoms in more than half of male patients.

High-Q Si microresonators formed by substrate transfer on silica waveguide wafers.

We report the first demonstration of Si microresonators (MRs) fabricated via substrate transfer on a silica waveguide (WG) wafer. Specifically, these Si microdisks were fabricated on a layer of Si (0.16-0.2 µm thick) that was directly-bonded on a silica waveguide wafer. We measured the throughput and drop spectrum of these microdisks when coupled to bonded silica waveguides, and observed loaded quality-factors (Qs) of ≥10(4). We modeled, in addition, the dispersion of whispering gallery modes in these microdisks to show phase-matched coupling with an incident silica waveguide or fiber-taper. Using the measured extinction ratio and loaded-Q, we evaluated, in addition, the coupling coefficient between the incident waveguide/taper and Si MR.

Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients.

OBJECTIVE: The Fecal Incontinence Severity Index (FISI) is widely used in the assessment of patients with faecal incontinence, but the relationship between FISI and the measurements of quality of life, such as the Fecal Incontinence Quality of Life Scale (FIQL) and the Medical Outcomes Survey (SF-36) has not been evaluated previously. The aim of the present study was to evaluate the relationship between disease severity and quality of life in a large cohort of patients. METHOD: Five hundred and two consecutive patients (84.4% female, mean age 56 years) were evaluated for faecal incontinence between May 2004 and October 2005. Patients completed FISI, FIQL and SF-36 questionnaires. Pearson's coefficients were determined for the relationships between FISI and subscales of FIQL and SF-36. Quality of life scores were compared between groups of patients with different levels of incontinence severity (mild, moderate, severe) using Student's t-test. RESULTS: Sixty-eight per cent of patients were incontinent of solid stool, 62% of liquid stool, and 90% of gas or mucus. The average FISI score was 36 (0-61). Moderate correlations were found between FISI and all subscales in FIQL (negative 0.29 to 0.41; P < 0.0001). Weak correlations were found between FISI and the social functioning (-0.21) and mental health (-0.17) scales in SF-36 (P < 0.05). Scores on the FIQL differed significantly between mild, moderate and severe incontinence. CONCLUSION: FISI was only moderately correlated with a disease-specific quality of life measurement (FIQL). Even though this supports the common assumption that the quality of life in the patients with faecal incontinence worsens with an increase in disease severity, it also stresses the need of measuring both variables to determine the true impact of any treatment.

Factors influencing patient satisfaction with GI endoscopy.

BACKGROUND: A modified Group Health Association of America-9 survey (mGHAA-9) was recently proposed for measurement of patient satisfaction with endoscopy. It is unknown whether the mGHAA-9 addresses the issues most important to this outcome. METHODS: A 15-item survey of factors potentially important to patient satisfaction with endoscopy was developed, including the 6 core mGHAA-9 items. Respondents were asked to rank the factors from 1 to 15 (1 = most important to l5 = least important to satisfaction). Two groups were surveyed: (1) patients with prior endoscopy experience and (2) physician endoscopists. Item rank distributions overall and by patient age, gender, and procedure experience were examined. RESULTS: Of 559 outpatients surveyed, 437 (78%) provided complete responses. The mean patient age was 59 years (48.7% female, 45.3% male, 6% not stated). The number 1 ranked factor was the endoscopist's technical skills (median ranking (mr) = 1), an item included in the mGHAA-9. Pain control, a factor not assessed by the mGHAA-9, was second (mr = 4), and ranked number 1 by 16% of patients. Item rankings were consistent across patient subgroups. Relative to patients, endoscopists underprioritized preprocedure and postprocedure communication. CONCLUSIONS: The mGHAA-9 has inadequate content validity for measurement of patient satisfaction with endoscopy because it does not assess pain control. However, endoscopy satisfaction measurement with a single, universally applied instrument appears feasible.

Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease.

OBJECTIVES: Brief, reliable, and valid self-administered questionnaires could facilitate the diagnosis of gastroesophageal reflux disease in primary care. We report the development and validation of such an instrument. METHODS: Content validity was informed by literature review, expert opinion, and cognitive interviewing of 50 patients resulting in a 22-item survey. For psychometric analyses, primary care patients completed the new questionnaire at enrollment and at intervals ranging from 3 days to 3 wk. Multitrait scaling, test-retest reliability, and responsiveness were assessed. Predictive validity analyses of all scales and items used specialty physician diagnosis as the "gold standard." RESULTS: Iterative factor analyses yielded three scales of four items each including heartburn, acid regurgitation, and dyspepsia. Multitrait scaling criteria including internal consistency, item interval consistency, and item discrimination were 100% satisfied. Test-retest reliability was high in those reporting stable symptoms. Scale scores significantly changed in those reporting a global change. Regressing specialty physician diagnosis on the three scales revealed significant effects for two scales (heartburn and regurgitation). Combining the two significant scales enhanced the strength of the model. Symptom response to self-directed treatment with nonprescription antisecretory medications was highly predictive of the diagnosis also, although the item demonstrated poor validity and reliability. CONCLUSIONS: A brief, simple 12-item questionnaire demonstrated validity and reliability and seemed to be responsive to change for reflux and dyspeptic symptoms.

Uncovering the missing Medicaid cases and assessing their bias for estimates of the uninsured.

General population surveys of health insurance coverage are thought to undercount Medicaid enrollment, which may bias estimates of the uninsured. This article describes the results of an experiment undertaken in conjunction with a general population survey in Minnesota. Responses to health insurance questions by a known sample of public program enrollees are analyzed to determine possible reasons for the undercount and the amount of bias introduced in estimates of uninsured people. While public program enrollees often misreport the type of coverage they have, the impact on estimates of those without insurance is negligible. Restrictions to generalizing the finding beyond this study are discussed.

How EverCare nurse practitioners spend their time.

OBJECTIVES: To describe how nurse practitioners (NPs) employed by EverCare, a Medicare HMO serving exclusively nursing home residents, spend their working days. DESIGN: A descriptive study based on structured self-reports. SETTING: Nursing homes. PARTICIPANTS: Seventeen NPs employed by EverCare in five sites. MEASUREMENTS: Self-reports of time spent over a 2-week period and specific reports of how time was spent on selected cases. RESULTS: NPs spend about 35% of their working day on direct patient care and another 26% in indirect care activities. Of the latter, 46% of the time was spent interacting with nursing home staff, 26% with family, and 15% with the physicians. The mean time spent on a given patient per day was 42 minutes (median 30); of this time 20 minutes was direct care (median 15). CONCLUSIONS: NPs' activities are varied. Much of their time is spent communicating with vital parties, an important function that supports the physicians' primary care role and should enhance families' satisfaction with care.

Comparison of interactive voice response and written self-administered patient surveys for clinical research.

This study compared the use of an interactive voice response (IVR) system with a written survey to collect data. Consecutive patients seen in an orthopedic clinic completed the Short Musculoskeletal Function Assessment (SMFA) by either IVR or written questionnaire and then were asked to complete the form again 3-7 days later using the opposite modality. Patient response rates were analyzed for differences between the self-administered IVR and written modes of administration. Three orthopedic clinics participated in the study. No significant differences between method of administration or individual differences in response per patient were found. Therefore, no significant differences in measurement are found when IVR is compared to the written SMFA.

Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type x frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type x frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States.

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

A comparison of suicidal and nonsuicidal elders referred to a community mental health center program.

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.

Consumer and professional ratings of the importance of functional status components.

As the population ages and chronic disease becomes the more dominant form of illness, measures of functional loss and disability assume greater importance in the assessment of both quality of life and the cost-effectiveness of care. The authors studied the responses of consumers and health care professionals regarding the impact on dependency of various levels of disability. Striking differences in perception were noted, raising concerns about the ability of those providing care to assume that the recipients share their values about what is important. This study makes clear the need for more research on functional outcome measurements that incorporate the values of consumers.

A model gatekeeper program to find the at-risk elderly.

This article describes the client characteristics and services needs of community-dwelling older adults found through a unique case-finding model developed at the Spokane Mental health Center. The model trains the employees of community businesses and corporations who work with the public to serve as community gatekeepers by identifying and referring community-dwelling older adults who may be in need of aging and/or mental health services. These community case-finders perform a gatekeeping function for older adults that is similar to that performed by schools and the workplace for younger persons. Information was collected on 777 individuals aged 60 and older referred over an 18-month period (January 1, 1994, to June 30, 1995) to the Spokane Mental Health Clinical Case Management Program in Spokane, Washington, which provides aging and mental health services to older adults residing in the county. Findings indicate that 40% of clients referred were found by community-based gatekeepers. Clients referred by gatekeepers were more frequently socially isolated, economically disadvantaged, and less likely to have a physician. Gatekeeper clients were also more likely to be women and to be younger than others referred to the agency. Gatekeeper clients were receiving fewer services at referral and were identified as needing more services at intake. Gatekeepers find a distinct population of community-dwelling older adults who are not found by more traditional referral sources. The need to integrate this model within a comprehensive clinical case management system is discussed.

Reliability of electron beam computed tomography to detect coronary artery calcification.

Electron beam computed tomography (CT) provides a safe, rapid, and noninvasive means to detect the presence and quantitate the deposition of calcium in the coronary arteries. To examine the reproducibility of a coronary calcification screen using electron beam CT, 50 subjects underwent two studies, averaging 12 minutes between studies. The number, volume, and calcification scores were determined for each artery as well as a total score of coronary calcification. Thirty-four of the 50 subjects had evidence of coronary calcification. The reliability score for total coronary artery calcification was 0.99. The reliability score for the total number of lesions and total volume was at or above 0.98. There were 8 cases in which a negative calcium score on retest was positive or where a positive calcium score on retest was negative. In both instances, the amount of calcium detected was very small. Therefore, evidence suggests that electron beam CT is reliable in the detection of coronary artery calcification and may be a useful tool for the early detection of coronary atherosclerosis before flow impairment.