专英实验考试内容-Manuscript

Prevalence and Risk Factors of Urinary Incontinence for Post-Stroke Inpatientsin Southern ChinaAbstractAims: The prevalence and risk factors of urinary incontinence (UI) for post- stroke inpatients remain unclear. In this study, we aimed to investigate the risk factors associated with the development of UI for post-stroke inpatients in southern China. Design: cross-sectional survey.Subjects and methods: a total of 711 post-stroke patients from neurological units at 8 different hospitals in Guangzhou, a city in southern China, were interviewed face to face. Data were collected by a self-designed questionnaire which includes sociodemographic variables, characteristics of stroke, and medical history. Results: the prevalence of UI among post-stroke inpatients was 44.3%. By multivariate logistic regression, we found that major risk factors for UI included health care assistant care (OR=3.935), hemorrhagic stroke (OR=1.755, 95%), mixed stroke (OR=2.802), parietal lobe lesion (OR=1.737), chronic cough (OR=2.099), aphasia (OR=3.541) and post- stroke depression (OR=3.398).Conclusions:The prevalence of UI among post stroke inpatients is high. Stroke inpatients looked after by health care assistant, hemorrhagic stroke, mixed stroke, parietal lobe lesion, chronic cough, aphasia and post- stroke depression were high-risk groups for UI. These patients should be targeted when planning intervention programs.Keywords: post- stroke, urinary incontinence, prevalence, risk factorsINTRODUCTIONUrinary incontinence (UI) is one of the most common and disruptive complication after stroke. About 40-60% of patients admitted to the hospitals after stroke encounter problems of UI1. Although some resolution of UI occurs with time, a significant number of patients remain incontinent at 1 year2. A recent study has shown a rate of persistent UI at 1 year of 37.7%3. UI affects the patient’s physical and psychological wellbeing. Physically, reduced bladder control may cause skin integrity breakdown, dermatitis, and urinary tract infections4-6. Psychologically, persistent UI can cause embarrassment and low-self esteem7-9. Besides, persistent UI increases the economic burden on patients; the average daily health care cost is estimated to be $ 185.60 per post stroke patient with UI, it is $ 28.78 higher than post stroke patients without UI10. UI is also a strong prognostic factor of poor post stroke outcome11-13. Patients with UI have moderate or severe disability and high mortality, with 52% death by discharge, and 60% within 6 months of the stroke14. UI after stroke has been shown to be strongly related to the likelihood of institutionalization compared to those who remain or regain continence15,16. Therefore, more understanding of the risk factors pertaining to UI has critical clinical significance17; structured assessment and management of care to reduce post-stroke UI and the related adverse outcomes may be of benefit. Several studies show that post-stroke UI was related to multiple factors. Gelber and colleagues suggested that three mechanisms were responsible for post-stroke UI: (1) disruption of neuromicturition pathways; (2) stroke-related cognitive or language deficits; (3) overflow incontinence and bladder hyporeflexia from concurrent neuropathy or medication use18. Further studies showed that parietal lobe, frontal lobe and internal capsule lesion were associated with UI19,20and hemorrhagic stroke exhibited higher risk of UI than ischemic stroke19,21,22, although Nakayama failed to find the correlation between stroke type and UI14,16. Aphasia and cognitive impairments18,23,24, age, history of diabetes or hypertension14,16,18,21,25have been consistently associated with UI, with some other exception16,18,25.Despite many studies indicated the risk factors for post-stroke UI, the evidence on prevalence and risk factors of UI are still contradictory and confusing, depending on study design, definition of UI or ethnicity. In China, the incidence of stroke varies from 136/100,000 to 441/100,000, and stroke has become the leading cause of death26,27. Nowadays, many studies focus on the progress of the disease and treatment of stroke, but less attention has been paid to the risk factors for post-stroke UI. The purpose of this study was to investigate the correlation of risk factors and prevalence of UI among post-stroke inpatients in southern China, in order to provide some clinical evidence for prevention of UI, decreasing its impact and related healthcare problems after stroke.METHODSSubjects and DesignA cross-sectional survey of post-stroke inpatients in the neurological unit at 8 different hospitals in Guangzhou, a city in southern China, was conducted from December 2010 to July 2011. Medical records were screened and subjects were included according to the following criteria: (1) older than 18 years old; (2) stroke, defined according to the criteria of the Fourth National Academic of Cerebrovascular Disease in China28and confirmed by computed tomography(CT) scan or magnetic resonance imaging (MRI), and (3) no subarachnoid hemorrhage. The subjects were excluded based on the following criteria: (1) a prior history of UI; (2) other severe neurological and spinal cord diseases including Parkinson's disease, multiple system atrophy, A lzheimer’s disease, etc; and (3) disturbance of consciousness or other deficits rendering the investigation impossible.On basis of consulting experts in related fields and referring to relevant literature, a questionnaire was designed and was administrated by research team members. When reliable answers could not be secured directly from participants (owing to cognitive impairment, communication difficulties, or severe illness), the information was sought from a family member, caregivers or hospital staff. Baseline information on sociodemographics and medical history was obtained from medical records. Medicalinformed Consent (MIC) was gained, before the interview, from all participants or their family members.Data CollectionExplanatory variables included sociodemographic variables (gender, age, education level, marital status, caregiver, and Body Mass Index (BMI), characteristics of stroke (type and location), medical history (chronic diseases, aphasia, and post-stroke depression).The symptom-based International Continence Society (ICS) definition was adopted, ―a complaint of involuntary loss of urine‖29. UI was defined as having lost bladder control or having an indwelling catheter within 48 hours of assessment16. Caregivers were categorized into family, health care assistant, and none.Health care assistants were not professionally trained; they stayed with the patients and provided daily care under nurse’s instruction. However, they could not have engaged in professional nursing30.Body Mass Index (BMI) was defined as the individual’s body weight (kg) divided by the square of height (meter). BMI＜18.5kg/m2were classified as underweight, 18.5~22.9 kg/m2 as normal weight, 23.0~24.9 kg/m2 as pre-obese, 25.0~29.9 kg/m2 as obese class I，≥30.0 kg/m2 as obese class II, based on the guidelines for prevention and control of overweight and obesity in Chinese adults31.Stroke type and location was confirmed by a stroke physician and a radiologist independently based on CT/MRI scans.Chronic diseases included diabetes mellitus, hypertension, coronary heart disease, hyperlipidemia, hyperuricemia, chronic cough. Chronic cough was defined as chronic persistent cough more than 8 weeks.The diagnosis of post stroke depression was made by World Health Organization Composite International Diagnostic Interview (WHO-CIDI), based on Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV).Data AnalysisSociodemographic characteristics of participants were presented as mean and standard deviations (SD) for continuous variables and frequencies and proportions for categorical variables. Differences of risk factors between the UI group and non-UI group were analyzed by χ2or Z test. Multivariate logistic regression analysis with forward stepwise selection was used to control for possible confounding variables and to determine the independent association between the risk factors and UI. Variables associated with UI in univariate models were entered into multiple models. Results were presented as odds ratio (OR) with 95% confidence interval (95%CI). SPSS version 13.0 for Windows (SPSS Inc., Chicago, IL) was used for statistical analysis, and P-value＜0.05 was considered statistically significant.RESULTS723 subjects were recruited into this study. An additional 12 subjects were excluded because of incomplete information, leaving 711 eligible for this study. Among them, 247 (34.7%) were female and 464 (65.3%) were male. The average age was 65.3±13.1 (ranged 20~99 years). The stroke types were identified as 578 (81.3%) ischemic, 104(14.6%) hemorrhagic and 29(4.1%) mixed. The sociodemographic variables, stroke characteristics and medical history of the participants are presented in Table 1.Table 1 Sociodemographic data, stroke characteristics and medical history of 711participantsPrevalence and Risk FactorsA total of 315 (44.3%) inpatients exhibited post-stroke UI. The proportions of ischemic stroke, hemorrhagic stroke, mixed stroke with UI were 241 (76.5%), 55 (17.5%), 19 (6.0%), respectively.In univariate analysis, there were significant differences in the following factors between patients with and without UI: gender, age, marital status, long-term caregiver, stroke type, frontal lobe lesion, temporal lobe lesion, parietal lobe lesion, coronary heart disease, chronic cough, aphasia, and post-stroke depression (Table 2).Table 2 Univariate comparison between UI vs non-UI participantsMultivariate logistic regression analysis showed the risk factors for UI among post-stroke inpatients (Table 3). Inpatients cared for by health care assistants had much higher incidence of UI (3.9 times) compared to those without. Ischemic stroke compared to hemorrhagic stroke and mixed stroke had an OR of 1.755 and 2.802, respectively. Patients with parietal lobe lesion had 1.7 times higher incidence of UI compared to other lesion in the brain after stroke, while chronic cough 2.1 times, aphasia 3.5 times, post-stroke depression 3.4 times. Marital status was not identified as a risk factor for UI.Table 3 Multivariate Logistic Regression Analysis of Risk Factors for UI AmongPost-stroke InpatientsDISCUSSIONAlthough there are variations on the reported prevalence of post-stroke UI reported, it is generally agreed that UI is a common complication after stroke. Consistent with the previous reports that the prevalence of post-stroke UI was 32~79% or 40~60%1,32, the prevalence of UI in our study was 44.3%.Our study showed the risk factors associated with post-stroke UI were type of stroke, parietal lobe lesion, chronic cough, aphasia, and post-stroke depression, which are reported in the previous studies18-22,24,25. Interestingly, marriage decreased the risk of UI more than one third, which supported the hypothesis widowed patients with stroke might be apt to suffering UI.An unexpected finding in this study was that the patients looked after by health care assistants had an increased risk of UI of 3.9 times compared to those without such caregivers. Although these patients were usually had more severe strokes and stroke severity has been reported to be related to UI3, the untrained health care assistants can only be involved in the basic personal hygiene care under the nurse’s instruction. Due to lack of effective communication with the patients, these health care assistants usually cannot meet the patients’ needs33. The health care assistants’duty of care is also different to family care. Therefore, it may not be surprising thatthese inpatients suffered more UI. Our findings demonstrated concern for severe stroke patients and supervision of health care assistant.At the same time, we found that post-stroke depression was a risk factor of UI. Most studies reported that a link between depression and UI in population-based studies34-36. However, few studies concerned the association between post-stroke depression and UI. Post-stroke depression is among the most common emotional disorders afflicting stroke patients. It impedes the rehabilitation and recovery process, jeopardizes quality of life and increases mortality37,38. In the current study, 80（11.25%）stroke patients suffered from post-stroke depression; of 57(71.3%) patients with UI. The post-stroke depression patients suffered from mood abnormalities, psychomotor retardation, impairment of executive functions, impaired activities of daily living may not have been to handle a urinal or transfer to a commode to adequately maintain continence. However, as this study was cross- sectional study, we are not able to determine specific reasons.Additionally, previous studies reported that chronic bronchitis and chronic obstructive pulmonary disease were potential risk factors for UI39,40. Chronic coughing is one of the most common clinical manifestations of these diseases. In the logistic regression analysis, chronic cough was an independent risk factor for UI after stroke. This may be explained by the associated increased intra-abdominal pressure, which causes pelvic floor muscles, fascia, and ligament laxity, easily leading to the occurrence of UI41.We found similar risk factors for UI to previous studies. Gelber et al reported that a strong correlation between aphasia and the development of UI, partly because aphasic patients may not able to convey the need to void18, which is consistent with our study. We also confirmed that the stroke type and lesion were associated with UI reported in the previous study19. Hemorrhagic stroke has a 1.755 times higher risk of UI than ischemic stroke, mixed stroke has higher risk (2.802 times). In addition, parietal lobe lesion showed higher risk of UI19,20. However, the relationship between stroke type, lesion and type of bladder voiding is not clear, and further studies are needed.There were limitations in this study. Firstly, since it was a cross-sectional design, the causal relationship between risk factors and UI cannot be identified. Secondly, the patients were only from one city (Guangzhou) and this may not reflect the prevalence of UI and risk factors for stroke patients in the entire southern China, although thereare a population of over 10 000 000 people in this developed city. Further multi-centre studies should be conducted. Thirdly, we also did not distinguish between different types of UI.ConclusionsThis is the first cross-sectional survey to investigate the prevalence and risk factors of UI among post-stroke inpatients in southern China. The study extends previous findings on post-stroke UI. The prevalence of UI among post stroke inpatients was 44.3%. Care by health care assistant, hemorrhagic stroke, mixed stroke, parietal lobe lesion, chronic cough, aphasia and post-stroke depression are significant risk factors for UI after stroke. Marriage appeared to be a protective factor for post-stroke UI. This is the first study to report the negative correlation of health care assistant care with post-stroke UI. Management of health care assistants will be the focus of a future study. In the whole, this study suggests that these factors contribute to higher risk of UI among post-stroke inpatients. The incidence of UI in these high-risk patients might decrease by applying appropriate prevention programs according to the characteristics of the risk factors.ACKNOWLEDGMENTSThe participated hospitals are consisted of the following: NanFang Hospital of Southern Medical University; ZhuJiang Hospital of Southern Medical University; HeXian Memorial Hospital of Southern Medical University; The First Affiliated Hospital of GuangDong Pharmaceutical University; The First Affiliated Hospital of JiNan University; GuangZhou PanYu The People’s Hospital of ShiLou; GuangZhou PanYu Central Hospital; GuangDong 999 Brain Hospital. Thanks to stroke patients for their participation.We offer special thanks to Professor Jisheng Huang, Professor Jean-Jacques Wyndaele, Professor Haizhu Du for the kind contribution in preparation and revision of the manuscript and the anonymous reviewers for their useful comments and suggestions.REFERENCES1. Barrett J. Bladder and bowel problems after stroke. Reviews in Clinical Gerontology 2002;12:253-67.2. Mehdi Z, Birns J, Bhalla A. Post‐stroke urinary incontinence. International journal of clinical practice 2013.3. Williams MP, Srikanth V, Bird M, et al. Urinary symptoms and natural history of urinary continence after first-ever stroke—a longitudinal population-based study. Age and ageing 2012;41:371-6.4. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient a scientific statement from the American Heart Association. Stroke 2009;40:2911-44.5. Maggi S, Minicuci N, Langlois J, et al. Prevalence Rate of Urinary Incontinence in Community-Dwelling Elderly Individuals The Veneto Study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2001;56:M14-M8.6. Ersser SJ, Getliffe K, V oegeli D, et al. A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies 2005;42:823.7. Gross JC. A comparison of the characteristics of incontinent and continent stroke patients in a rehabilitation program. Rehabilitation Nursing 1998;23:132-40.8. Brittain K, Stroke R. Urinary symptoms and depression in stroke survivors. Age and Ageing 1998;27:P72-c-P3.9. Jørgensen L, Engstad T, Jacobsen BK. Self-reported urinary incontinence in noninstitutionalized long-term stroke survivors: A population-based study. Archives of physical medicine and rehabilitation 2005;86:416-20.10. Green JP, Smoker I, Ho MT, et al. Urinary incontinence in subacute care-a retrospective analysis of clinical outcomes and costs. Medical journal of Australia 2003;178:550-4.11. Pettersen R, Wyller TB. Prognostic significance of micturition disturbances after acute stroke. Journal of the American Geriatrics Society 2006;54:1878-84.12. Gariballa S. Potentially treatable causes of poor outcome in acute stroke patients with urinary incontinence. Acta neurologica scandinavica 2003;107:336-40.13. Patel M, Coshall C, Rudd AG, et al. Natural history and effects on 2-year outcomes of urinary incontinence after stroke. Stroke 2001;32:122-7.14. Nakayama H, Jørgensen H, Pedersen P, et al. Prevalence and Risk Factors of Incontinence After Stroke The Copenhagen Stroke Study. Stroke 1997;28:58-62.15. Kolominsky‐Rabas PL, Hilz MJ, Neundoerfer B, et al. Impact of urinary incontinence after stroke: Results from a prospective population‐based stroke register. Neurourology and urodynamics 2003;22:322-7.16. Patel M, Coshall C, Lawrence E, et al. Recovery from poststroke urinary incontinence: associated factors and impact on outcome. Journal of the American Geriatrics Society 2001;49:1229-33.17. Thomas L, Cross S, Barrett J, et al. Treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2008;1.18. Gelber DA, Good DC, Laven LJ, et al. Causes of urinary incontinence after acute hemispheric stroke. Stroke 1993;24:378-82.19. Sakakibara R, Hattori T, Yasuda K, et al. Micturitional disturbance and the pontine tegmental lesion: urodynamic and MRI analyses of vascular cases. Journal of the neurological sciences 1996;141:105-10.20. Burney TL, Senapti M, Desai S, et al. Acute cerebrovascular accident and lower urinary tractdysfunction: a prospective correlation of the site of brain injury with urodynamic findings. The Journal of urology 1996;156:1748-50.21. Du GQ, Shang XL, Huang LN, et al. Study on Risk factors of Urinary Incontinenceafter stroke. Shangdong Medical Journal 2005;45:26-7.22. Han KS, Heo SH, Lee SJ, et al. Comparison of urodynamics between ischemic and hemorrhagic stroke patietns; can we suggest the category of urinary dysfunction in patients with cerebrovascular accident according to type of stroke? Neurourology and Urodynamics 2010;29:387-90.23. Wilson D, Lowe D, Hoffman A, et al. Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004. Age and Ageing 2008;37:542-6.24. Engelter ST, Gostynski M, Papa S, et al. Epidemiology of aphasia attributable to first ischemic stroke incidence, severity, fluency, etiology, and thrombolysis. Stroke 2006;37:1379-84.25. Su YR, Wang J, Jiang YP. Prevalence, risk factors and outcomes of urinary incontinence in patients with stroke. J Apoplexy and Nervous Disease 2004;21:518-20.26. News Release Office, Ministry of Health of the People's Republic of China. Main finding from 3th nation-wide survery on major cause of death in Chinese. Bull Chin Cancer 2008;17:344-5.27. Fang XH, Wang CX, Mei LP, et al. Progress in epidemiology study on stroke. Chin J Epidemiol 2011;32:847-53.28. Chinese Society of Neurology. Classification of cerebrovascular disease (1995). Chin J Neurosurg 1997;13:3-5.29. Haylen BT, De Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International urogynecology journal 2010;21:5-26.30. Zhang R, Huang HG. Explore the socialized management model of nurse asssistants is hopital. Chinese Nursing Management 2010;10.31. Chen CM, Kong LZ. Guidelines for prevention and control of overweight and obesity in Chinese adults(trial edition). People’s Medical Publishing House; 2003.32. Brittain K, Peet S, Castleden C. Stroke and incontinence. Stroke 1998;29:524-8.33. Li RH. managemnt and countermeasures of health care assistant in China. Chin J Mod Nurs 2009;15:2.34. Avery JC, Stocks NP, Duggan P, et al. Identifying the quality of life effects of urinary incontinence with depression in an Australian population. BMC urology 2013;13:11.35. Stach‐Lempinen B, Hakala AL, Laippala P, et al. Severe depression determines quality of life in urinary incontinent women. Neurourology and Urodynamics 2003;22:563-8.36. Melville JL, Fan MY, Rau H, et al. Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample. American journal of obstetrics and gynecology 2009;201:490 e1-7.37. Gaete JM, Bogousslavsky J. Post-stroke depression. Expert review of neurotherapeutics 2008;8:75-92.38. Zavoreo I, Bašić-Kes V, Bosnar-Puretić M, et al. Post-stroke depression. Acta Clinica Croatica 2009;48:329-33.39. Uustal Fornell E, Wingren G, KjØlhede P. Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta obstetricia et gynecologica Scandinavica 2004;83:383-9.40. Jackson RA, Vittinghoff E, Kanaya AM, et al. Urinary incontinence in elderly women: findingsfrom the Health, Aging, and Body Composition Study. Obstetrics & Gynecology 2004;104:301-7. 41. Zhang C, Yan M. Research progress in urge urinary incontinence after stroke. China Modern Medicine 2009;16:10-1.11。