Camille P. Vaughan

Infections associated with haemophagocytic syndrome

Summary Haemophagocytic syndrome or haemophagocytic lymphohistiocytosis is a rare disease that is often fatal despite treatment. Haemophagocytic syndrome is caused by a dysregulation in natural killer T-cell function, resulting in activation and proliferation of lymphocytes or histiocytes with uncontrolled haemophagocytosis and cytokine overproduction. The syndrome is characterised by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hyperferritinaemia. Haemophagocytic syndrome can be either primary, with a genetic aetiology, or secondary, associated with malignancies, autoimmune diseases, or infections. Infections associated with haemophagocytic syndrome are most frequently caused by viruses, particularly Epstein-Barr virus (EBV). We present a case of EBV-associated haemophagocytic syndrome in a young adult with no known immunosuppression. We briefly review haemophagocytic syndrome and then discuss its associated infections, particularly EBV and other herpes viruses, HIV, influenza, parvovirus, and hepatitis viruses, as well as bacterial, fungal, and parasitic organisms.

Prevalence and trends of symptomatic pelvic floor disorders in U.S. women.

OBJECTIVE: To estimate the prevalence and trends of these pelvic floor disorders in U.S. women from 2005 to 2010. METHODS: We used the National Health and Nutritional Examination Survey from 2005–2006, 2007–2008, and 2009–2010. A total of 7,924 nonpregnant women (aged 20 years or older) were categorized as having: urinary incontinence (UI)—moderate to severe (3 or higher on a validated UI severity index, range 0–12); fecal incontinence—at least monthly (solid, liquid, or mucus stool); and pelvic organ prolapse—seeing or feeling a bulge. Potential risk factors included age, race and ethnicity, parity, education, poverty income ratio, body mass index ([BMI] less than 25, 25-29, 30 or greater), comorbidity count, and reproductive factors. Using appropriate sampling weights, weighted &khgr; analysis and multivariable logistic regression models with odds ratios and 95% confidence intervals (95% CIs) were reported. RESULTS: The weighted prevalence rate of one or more pelvic floor disorders was 25.0% (95% CI 23.6–26.3), including 17.1% (95% CI 15.8–18.4) of women with moderate-to-severe UI, 9.4% (95% CI 8.6–10.2) with fecal incontinence, and 2.9% (95% CI 2.5–3.4) with prolapse. From 2005 to 2010, no significant differences were found in the prevalence rates of any individual disorder or for all disorders combined (P>.05). After adjusting for potential confounders, higher BMI, greater parity, and hysterectomy were associated with higher odds of one or more pelvic floor disorders. CONCLUSION: Although rates of pelvic floor disorders did not change from 2005 to 2010, these conditions remain common, with one fourth of adult U.S. women reporting at least one disorder. LEVEL OF EVIDENCE: III

Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial

To compare the effectiveness of behavioral treatment with that of antimuscarinic therapy in men without bladder outlet obstruction who continue to have overactive bladder (OAB) symptoms with alpha‐blocker therapy.

The Prevalence of Clinically Meaningful Overactive Bladder: Bother and Quality of Life Results from the Population-Based FINNO Study

BACKGROUND Wide variation exists in prevalence estimates of overactive bladder (OAB) syndrome. OBJECTIVE To determine how the frequency of urinary urgency or urgency urinary incontinence (UUI)--the cornerstone symptoms of OAB--affects symptom-related bother, health-related quality of life (HRQL), and ultimately clinically meaningful prevalence. DESIGN, SETTING, AND PARTICIPANTS Questionnaires were mailed to 6000 subjects (18-79 yr of age) randomly identified from the Finnish Population Register in 2003-2004. MEASUREMENTS The frequency (scale: never, rarely, often, always) and bother (scale: none, small, moderate, major) of urgency and UUI were assessed using the Danish Prostatic Symptom Score (DAN-PSS). HRQL was measured with the generic 15D instrument. For HRQL analyses, respondents were classified according to six symptom categories by frequency of urgency and UUI. RESULTS AND LIMITATIONS Of those subjects queried, 62.4% responded to the survey (53.7% female). Any urgency was reported by more than half of all respondents (54.2% [95% confidence interval (CI), 51.6-56.7] of men; 56.9% [95% CI, 52.9-61.0] of women), whereas any UUI was reported by one in nine men (10.7% [95% CI, 8.9-12.4]) and one in four women (25.7% [95% CI, 22.8-28.7]). However, only one in seven of all respondents with urgency and less than one in three with UUI reported at least moderate bother. With increasing OAB severity, statistically significant decreases were found in the total 15D score and on all 15D dimensions (p<0.001 for all). Reporting often urgency without UUI or rare urgency with rare UUI is associated with a clinically important decrease in HRQL. Although the response proportion was high, approximately one-third of those contacted did not participate. CONCLUSIONS Increased severity of urgency and UUI is associated with a statistically significant and clinically important decrease in HRQL. Assessing bother associated with OAB drastically modifies the measured OAB prevalence and accounts for variation among studies.

A multicomponent behavioural and drug intervention for nocturia in elderly men: rationale and pilot results

To evaluate the number of medical and urological conditions associated with nocturia in a cohort of older men who were primary‐care enrolees, and to assess the feasibility and efficacy of using a multicomponent intervention to reduce nocturia and its bother.

The association of nocturia with incident falls in an elderly community-dwelling cohort.

Objective:  The aim of this study was to examine the association of nocturia with incident falls in a population‐based sample of community‐dwelling elderly persons.

Prevalence of nocturia in United States men: results from the National Health and Nutrition Examination Survey.

PURPOSE We estimated the prevalence of nocturia in the United States male population and identified associated factors. MATERIALS AND METHODS Data were analyzed for 5,297 men (20 years old or older) who participated in the 2005-2006 and 2007-2008 cycles of the NHANES, a cross-sectional survey of the United States noninstitutionalized population. Getting up 2 or more times at night to urinate was coded as nocturia. Potential factors included age, race/ethnicity, education, waist circumference, self-reported health status, chronic diseases, and prior diagnosis of benign prostatic enlargement and/or prostate cancer (men 40 years old or older). Prevalence and prevalence odds ratios were estimated from a multivariable logistic regression analysis using appropriate sampling weights. RESULTS The prevalence of nocturia was 21% (weighted 95% CI 19.3-23.0). Nocturia increased in prevalence with age (p<0.001) from 8.2% (CI 6.7-10.2) in men 20 to 34 years old up to 55.8% (CI 51.3-60.2) in men 75 years old or older. More nonHispanic black men had nocturia (30.2%, CI 26.7-34.1) than other racial/ethnic groups (20.1%, CI 18.1-22.1, p<0.001). Significant factors included 10-year increase in age (POR 1.5, CI 1.5-1.6), nonHispanic black race/ethnicity (POR 2.0, CI 1.6-2.7), fair/poor self-rated health (POR 1.5, CI 1.2-1.9), major depression (POR 2.5, CI 1.6-3.9), hypertension (POR 1.4, CI 1.0-1.9) and arthritis (POR 1.3, CI 1.0-1.7). Among men 40 years old or older benign prostatic enlargement (POR 1.4, CI 1.1-1.8) and prostate cancer (POR 1.6, CI 1.0-2.4) were associated with nocturia. CONCLUSIONS After adjusting for age and race norms nocturia was common among United States men. NonHispanic black men had greater odds of nocturia even when controlling for other factors.

Behavioral therapy to treat urinary incontinence in Parkinson disease

Objective: To assess the feasibility and efficacy of exercise-based behavioral therapy to treat urinary incontinence (UI) in older adults with Parkinson disease (PD). Methods: Participants with PD ≥50 years with ≥4 UI episodes on a 7-day bladder diary were recruited from movement disorders clinics. In 5 visits over 8 weeks, participants learned pelvic floor muscle exercises using computer-assisted EMG biofeedback, and bladder control strategies including urge suppression. Bladder diaries were used to reinforce techniques and monitor the primary outcome of UI frequency. Secondary outcomes included additional reporting of lower urinary tract symptoms, symptom bother, and quality of life (QOL) using the International Consultation on Incontinence Questionnaire for overactive bladder (ICIQ-OAB). Results: Twenty participants were enrolled (90% male, age 66.5 ± 6.2 [mean ± SD], with PD for 6.9 ± 5.4 years) and 17 completed the study. The median (interquartile range) weekly frequency of baseline UI episodes was 9 (4–11) and following intervention was 1 (0–3), representing an 83.3% reduction (45.5–100.0, p = 0.0001). QOL scores on the ICIQ-OAB improved from 71.1 ± 23.9 to 54.7 ± 15.4 (p = 0.002). Conclusions: In this uncontrolled pilot study of an exercise-based, biofeedback-assisted behavioral intervention, older participants with PD demonstrated statistically significant and clinically meaningful reductions in frequency of UI and improvement in QOL. Randomized controlled trials to assess behavioral therapies for UI in patients with PD are warranted. Classification of evidence: This study provides Class IV evidence that exercise-based, biofeedback-assisted behavioral intervention can reduce UI frequency in patients >50 years old with PD.

Impact of Obesity on Urinary Storage Symptoms: Results from the FINNO Study

PURPOSE Urinary storage symptoms are the most common and most bothersome urinary symptoms. Many studies on the relation between body weight and urinary symptoms have focused on urinary incontinence in women. We evaluated the association of obesity with urinary storage symptoms in a population based study of men and women age 18 to 79 years old. MATERIALS AND METHODS Questionnaires were mailed to 6,000 adults randomly identified from the Finnish Population Register. Self-reported height and weight were used to calculate body mass index. Urinary frequency, nocturia, urgency, stress urinary incontinence and urgency urinary incontinence were assessed using validated instruments. Multivariate logistic regression analyses (adjusted for age, comorbidity and medications, and sociodemographic, lifestyle and reproductive factors) were performed to evaluate associations between body mass index and each symptom. RESULTS Of the 6,000 individuals approached 3,727 participated (62.4% response, 53.7% women). In men and women obesity was associated with nocturia (adjusted OR 2.0, 95% CI 1.2-3.3 for men; OR 2.4, 95% CI 1.5-3.8 for women) but not with urgency (adjusted OR 1.2, 95% CI 0.7-2.3 for men; OR 1.2, 95% CI 0.7-2.1 for women). In men obesity was also associated with urinary frequency (OR 2.0, 95% CI 1.0-3.9), and in women it was associated with stress urinary incontinence (OR 1.9, 95% CI 1.2-3.0) and urgency urinary incontinence (OR 3.0, 95% CI 1.2-7.4). However, the number of men with stress urinary incontinence or urgency urinary incontinence was insufficient for precise analyses. CONCLUSIONS This study extends previous research by providing symptom specific associations between obesity and urinary storage symptoms in a population based sample of men and women. Obesity impacts individual urinary storage symptoms differently and these associations may be influenced by gender.

Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.

Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha‐blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy.