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Dr. Langley Bell
View Image Gallery
"22 Classmates from Pensacola High School"
Langley Madison Bell, Jr. grew up in Pensacola and attended Pensacola High School, graduating in 1940. He attended the Citadel, along with about ten of his classmates from PHS. Bell's entire class at the Citadel was inducted en mass into the military. Bell transferred to the US Air Force, where he became a B-24 navigator-bombardier.
"Our B-24 crew of ten consisted of four 2nd Lieutenants – a pilot, Ray Roberts; co-pilot, Bill Wilson; me as the navigator and a guy named Ferguson as the bombardier. Our crew also included six enlisted men, including the engineer, nosegunner, tailgunner, ball-turret gunner and two waist-gunners," recalled Bell. "Our average age was seventeen to twenty-two years old. In fact, I was the oldest at age twenty-two. Our crew landed in Chregnolo, Italy to fly with the 15th Air Force where we participated in missions over Austria, Germany, Northern Italy and Greece. Our B-24F was nicknamed the "Flying Boxcar."
On one attack mission over Austria, Bell's aircraft was struck by anti-aircraft fire and slightly disabled. "Before reaching our initial point for a bombing run, we experienced the first German jet fighter plane we had ever seen, and it made a pass at us. We were struck by anti-aircraft guns and pieces of metal penetrated our plan over 35 or 40 times." Air Force P-51s from the all-black Tuskegee Airmen 332nd fighter group were dispatched to aid the disabled bomber against further attack. As Bell's plane approached the landing area, the P-51 fighters peeled away. A voice with a distrinctly southern accent radioed to Bell's plane, saying, "Y'all are safe now. See yo' later!"
"When I returned home to Pensacola after the war in 1945, I discovered that twenty-two classmates from Pensacola High School – graduates from the years 1934 to 1944 – had been killed in WWII," Bell recounts. These men included Bob Campbell, Alfred Pipkin, Tommy Loggins, Charley Mankin, Doyle Nee, James "Pickle" Forte, Tommy Galey, Glen Connor, "Bubba" Arrington, Jim Folmar, Leo Carvalis, "Buddy" Dubuison, B.J. Nettles, John Holm, "Rosie" Scholl, Tommy Stanley, Bobby Oliver, and Archie Mills.
"There were quite a few sacrifices during WWII. Everybody sacrificed without any qualms about it. You just did it," Bell states. "It was natural instinct to fight for your country. The sacrifice that my classmates gave in winning the battles of Europe and Japan were tremendous sacrifices. So many of them gave their lives to serve their country. They volunteered and served with pride, with a lot of pride."


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ADA News
Officite is first provider to launch ADA Web Developer Program
The American Dental Association has selected Officite as the first provider to launch the Association's Web Developer Program.
Officite, a dental website and Internet marketing company that is not affiliated with the ADA, was selected to operate as an independent contractor under this new member benefit program developed by the Association.
Officite now offers web-based ADA patient education brochures and Toothflix videos, which can be used on dental practice websites. Dentists can contact Officite to help build a website for their practice; discuss how to get the best placement among Google or other search engine results; work on social networking; and add ADA-branded brochures and videos to their website.
"Having the branded content from the ADA is the most exciting thing for the dentist because the patient sees the content that is on their dentist's website is endorsed and created by the ADA," said Glenn Lombardi, Officite president.
Officite was founded in 2002 and is recognized for its website designs and marketing solutions for the medical community. The ADA Web Developer Program was created in response to members wanting ADA patient education brochure content—formerly only available as printed leaflets—and Toothflix videos on their websites. The ADA collaborates with web developers, which have the technical expertise of developing and hosting websites.
Through its print and electronic catalogs, the ADA already sells patient brochures and Toothflix DVDs to dentists to display or show in their offices. But as dentists' presence on the Web increases, the Association is expanding to make its content available online.
Dentists interested in creating a professional website, which includes ADA-branded patient education materials, should visit Officite's special ADA member page at www.officite.com/ada.
The ADA's Web Developer Program is not exclusive to Officite—the Association is interested in recruiting more dental website providers to join the program. For more information, contact Debbie Labinger, licensing coordinator, at email@example.com.
An article about dental practice websites is also posted online here.

subset: commoncrawl


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FROM ROCKFORD POLICE: On Sunday, May 19th, 2013 shortly before 9:00 AM, Rockford Police Department patrol officers responded to the Burger King Restaurant located at 2434 11th Street in reference to an Armed Robbery. Upon arrival to the business, officers were provided with a description of the suspect and suspect vehicle which had fled from the scene. An undisclosed amount of United States currency was taken during the Armed Robbery.
Patrol officers located the suspect vehicle parked at an address in the 2600 block of 20th Avenue. Possible suspects were located and taken to the Public Safety Building for questioning.
Rockford Police Detectives conducted follow up investigation into the incident. The facts of the investigation were reviewed by the Winnebago County State's Attorney's Office. The following charges were authorized:
Christopher L. Tillman, 28 years of age, Janesville, Wisconsin
Armed Robbery
Conspiracy to Commit Armed Robbery
Echo M. Miller, 27 years of age, Rockford, Illinois
Armed Robbery
Conspiracy to Commit Armed Robbery


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Only Seven Left makes own boys dreams come true. On September 24 is the debut of the young piano rock band Only Seven Left out. The CD titled 'It Was All A Dream 'is the theme of dreams. In the CD booklet contains photos of the worst nightmares of band members: haunted by a mega spin with a finger on a skyscraper and dangling end up a war. The release of the album will be celebrated with a tour in the Netherlands with venues like Paradiso, 013 and Tivoli. Only Seven Left, are five boys from Hilversum aged 16 to 26 years, has a common dream: to break through pop songs with content to play. Besides catchy melodies and melancholic piano texts is the main ingredient for the fresh sound of the band. Wake Up Call. Past several years were all dreams: the no-budget music video for first single Wake Up Call was frequently along on TMF, 3FM DJ Coen adopted the band for five weeks as manager, Q-music. Wake Up Call bombarded daily wake-up-word album, Only Seven Left and played in Ahoy (rotterdam). program for Tokio Hotel and was a sold out tour with their friends Destine. Egypt and sprinkles. Previously the band back in the main hall of Paradiso with the dike as a program for Metro Station the Milky Way, and for thousands of screaming girls at the Tina day (magazine for young girls) . Also a tour of Egypt, rave reviews of 3voor12, Music Magazine OOR and LiveXS and an interview at 50,000 packs sprinkles contributed to the awareness of Only Seven Left. Fans, Meanwhile the fanbase is growing steadily, ask any teenage girl to Only Seven Left and the chances she Bart (23 years, vocals and guitar), Hinne (16 years, bass), Jochem (19 years, guitar), Roderick (22 years, piano) and Bram (26 years, drums) is called by name. Including by actively Twitter, and blogging Hyving and fans starring in their video clips to play, the boys have a unique working relationship with the public. Friends Also within the band, special click: Hinne Jochem and his brothers, the rest know each other through school and other bands. Since they play together is one of friends have become inseparable. Outside the band activities to bring almost all free time together: an atmosphere that you immediately see the stage. Only Seven Left are proud to announce that they will be playing a handful of club shows in late September October. These gigs will coincide with the release of the widely anticipated and hotly tipped debut album to be released on september 25th
The dates in full are:
4 sept Summer Square, Hengelo
11 sept Duycker Buyten, Hoofddorp
24 sep Tivoli de Helling, Utrecht (tour)
25 sep Rotown, Rotterdam (tour)
26 sep Tinadag, Wassenaar
2 okt NS station, Amersfoort
8 okt NS station, Groningen
15 okt NS station, Leiden
21 okt Paradiso, Amsterdam (tour)
22 okt 013, Tilburg (tour)
23 okt NS station, Eindhoven
29 okt Nieuwe Nor, Heerlen (tour)
30 okt Paard van Troje, Den Haag (tour)


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Declined Offer
Positive Experience
Easy Interview
I applied through college or university and the process took 2 weeks - interviewed at McGladrey LLP in February 2013.
Interview Details Basic college recruit. Applied through campus career center. Meet some partners and recruiters at the career fair. Selected for on-campus interview. 1on1 interview with tax partner. Awesome guy, nice conversations. Basic questions, just to get to know you and you're interests in the firm and accounting. Nothing technical. I think there were a few questions on teaming, but those came up naturally in the convo. Invited to the office visit and notified the day following. The office visit was the following week. Meet with two partners for 45 minutes each. Very down to earth people and they just asked about your experiences and why you would want the internship and work in public accounting. I got the offer the monday after following the friday interview.
Interview Question – Nothing too unexpected. In my opinion, the good firms these days just want to get to know you. Answer Question
Reason for Declining – Went with a Big 4 firm I felt more comfortable with. Basically, the only reason was because the McGladrey office was more boring and bleak (furniture and layout wise) compared to the big 4 I am going with. McGladrey is impressive anyhow.
McGladrey LLP is the largest U.S. provider of assurance, tax and consulting services focused on the middle market, with nearly 6,700 people in more than 75 cities nationwide. McGladrey is a licensed CPA firm. It is the… — Full Overview
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OMG, WTF and LOL Decorative Pillows
Published by Sierra Monica B. on October 6, 2011 under Home Decor Gadgets
Use these cool Chat Pillows to decorate your room and impress your friends. The OMG, WTF and LOL pillow not only make anyone laugh, but they also fit modern, minimalist home designs. Read more


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Balancing equipment, accessories
Even shops that don't specialize in tire service can take advantage of balancers
Although tire and wheel specialty shops tend to see higher volumes of wheel balancing, any independent shop should make balancing options available to customers. Even entry-level balancers now have more mid-range and premium features, making the world of wheel balancing faster and more intuitive — even for the most general repair shop.
Aside from selling the main equipment, there are other opportunities with wheel balancers. Even if shops have all the necessary equipment, find out if they need upgrades on accessories.
"A simple visual inspection of the cones, shafts and nuts make it obvious to even an untrained eye that the parts should be replaced," said Bruce Hartin, president of Haweka.
Manual to automatic
Wheel balancing systems have developed from complete manual operation to fully automatic, and both are still used today. Kevin Keefe, VP of marketing for Hennessy Industries, explained some of the differences.
"You have fully manual machines that the technician has to manually punch in the distance, diameter and width measurements," he said. "You've got what we call 2D machines, which give you distance and diameter automatically, using the data-entry arm.
"Then you've got 3D units, which are accomplished a couple different ways. We use a sensor in the hood. Other manufacturers use a second data-entry arm, where you can capture the width automatically."
Many wheel balancing units today offer multiple automatic features, including automatic distance arms.
"Before, you had to physically make some measurements and then plug them into the wheel balancer," said Andrew Randall, CEMB-USA product manager. "Now, when you take the measurement (with the automatic distance arm), it electronically feeds the measurement straight into the balancer."
The number of balances done per shop helps determine the entry-level vs. premium balancer a shop needs. In general, though, shops continue to buy units with what used to be considered high-end features, based on the functionality and longevity of the unit.
"Some of those features that used to be really just on premium machines, over the last three or four years have migrated into mid-range, and even on some, entry-level models," said Keefe.
"Overall, what we're seeing is a movement toward value. Just across segments what we've seen is users becoming more conscious of what they're getting for their money. They're not jumping up to the premium units. They're not valuing some of the premium functionality, like diagnostics, as much as they were, say, two or three years ago."
The world of accessories
If a shop already has a functioning, up-to-date wheel balancer, you can always upsell with accessories. Two types of accessories exist for shops that currently have wheel balancers: upgrades and replacements.
If shops aren't looking to upgrade, or don't have a high volume of tire work coming through the shop, look to offer replacement parts for current equipment.
Haweka, in particular, only makes balancer accessories as add-ons for current shop equipment.
"Certainly getting started on a tool truck, (distributors) want to go after the cones, the quick nuts and the shaft (accessories), because those are pretty simple to eyeball and say, 'Look, you need to replace this problem with your wheel balancer,' " said Hartin. "It's inexpensive and a great way for them to get their feet wet."
Beyond simple replacements, companies like Haweka offer additional accessories to upgrade existing units. Quick plates offer users an add-on to align the balancer with bolt holes of the wheel, eliminating the need for wheel charts. The quick plates allow technicians to mount a variety of different wheels without additional measurements.
Distributors who want to branch out into wheel balancer upgrades can offer demonstrations of the product to different shops, said Hartin.
Additional upgrades include kits for custom wheels as well as light truck and SUV applications, to customize wheel balancers for use on less common types of wheels.
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Spinning Wheels, Turning Profits
For wheel service, shops can't just change tires–they need to change minds
WP8300 Wheel Balancer
QuickPlate System


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A brief history of Chatham University...
Chatham University, a coeducational institution with three distinctive Colleges, was chartered on December 11, 1869, under the name Pennsylvania Female College. The Reverend William Trimble Beatty, pastor of the Shadyside Presbyterian Church, led a group of Pittsburghers in making the dream to provide women with an education comparable to that which men could receive at the time at "colleges of the first class." The founders were somewhat ahead of their time: 1869 was the year that the National Association of Women's Suffrage was established, and the year John Stuart Mill published The Subjection of Women. Pennsylvania Female College occupied what was then the largest private residence in Allegheny County - the George Berry mansion atop Fifth Avenue in Shadyside. Fifteen faculty and just more than 100 students occupied the 11-acre campus.
The College's first curriculum required proficiency of all students in Latin, French, or German; higher mathematics; history; English; natural sciences; systematic Bible history; and Anglo-Saxon. In succeeding years, electives ranging from modern literature to family living were added, and the number of required courses was reduced.
In 1890 the name of the institution was changed to Pennsylvania College for Women, and in 1955 the name was changed again to Chatham College in honor of William Pitt, First Earl of Chatham and namesake of the City of Pittsburgh. The Commonwealth of Pennsylvania granted university status in 2007, which was officially announced on May 1, 2007 and marks Chatham's newest tradition, University Day.
On May 1, 2008 Chatham received a gift unequaled in its history: the Eden Hall Campus from Eden Hall Foundation. Originally a farm and retreat for the working women of the H.J. Heinz Company, the Eden Hall Campus will be the home of Chatham's new Falk School of Sustainability. The University's Shadyside Campus expanded in June 2008 to include Chatham Eastside, an office complex at Fifth and Penn avenues approximately one mile from Woodland Road and home to the university's interior architecture, landscape architecture, nursing, occupational therapy, physical therapy and physician assistant studies programs.
A vision for the 22nd century...
The Falk School of Sustainability, founded June 2009, further expands the potential of the Eden Hall Campus and honors the legacy of its 1929 alumna and founder of the modern environmental movement, Rachel Carson. SSE will provide opportunities for the University's students to earn certificates and degrees through the master's level. The first program offered through SSE is the Master of Arts in Food Studies, which enrolled 30 students in its inaugural year. SSE will eventually be located at the University's Eden Hall Campus.
In fall 2010 the University selected David M. Hassenzahl, Ph.D. as the founding Dean of the School of Sustainability and the Environment. Dr. Hassenzahl is the coauthor of several books, including Should We Risk It? (Princeton University Press) with Daniel M. Kammen; Environment (J. Wiley and Sons), with Peter Raven and Linda Berg, and, most recently, Visualizing Environmental Science (J. Wiley and Sons), with Linda Berg and Mary Catherine Hager.
Dr. Hassenzahl is a Senior Fellow of the National Council for Science and the Environment, through which his climate change education efforts are supported by the Nation Science Foundation and the National Aeronautics and Space Administration. Prior to joining Chatham, he served recently as Chair and Associate Professor in the Department of Environmental Studies at the University of Nevada, Las Vegas. Recognition for his work includes the Society for Risk Analysis Outstanding Educator Award, the UNLV Outstanding Department Chair Award, and the UNLV Foundation Distinguished Teaching Award. He serves on the Council of the Society for Risk Analysis, and is Secretary of the Association of Environmental Studies and Sciences. In addition to his academic credentials, Dr. Hassenzahl has experience with sustainability and environmental management in both the public and private sectors.
In addition to his responsibilities at Chatham, Dr. Hassenzahl is currently the Principle Investigator for the Climate Adaptation and Mitigation E–Learning (CAMEL) project. CAMEL is a three–year effort funded by the National Science Foundation, though the National Council for Science and Environment (NCSE). Begun in October 2009, CAMEL has begun to improve undergraduate education on climate change causes, consequences, and solutions by engaging a community of faculty members and students in developing an extensive, vetted online collection of high–quality educational materials about the causes, consequences, mitigation, and adaptation associated with climate change. The project provides resources, training, and on–line professional networking opportunities for students and faculty engaged in studying climate change, using cyber–infrastructure built for the NCSE's Encyclopedia of Earth.
Dr. Hassenzahl holds a B.A. in Environmental Science and Paleontology from the University of California at Berkeley, and a Ph.D. in Science, Technology and Environmental Policy from Princeton University.
Chatham Traditions...
Traditions are an integral part of life at Chatham. Familiarity with the traditions is important to fully understand life on Chatham 's campus. Most traditional events involve not only the student, but the faculty, staff, and alumnae as well.
University Colors: Green and White
Chatham College for Women Colors: Purple and White
CCW Motto: Filiae Nostrae Sicut Antarii Lapides - That our daughters may be as cornerstones (polished after the similitude of a palace) - From Psalm 144
Class Colors: Each undergraduate class is pinned with their colors upon their matriculation to the college. Each year, one of the four colors is passed down from graduating seniors to incoming first years.
Opening Convocation marks the traditional opening of the academic and Global Focus year.
Battle of the Classes is a week-long event that has each class competing in several events.
Song Contest has been a tradition at Chatham for more than 70 years.
Candlelight, Fickes Eggnog, and the Holiday Ball is a grand semi-formal event to celebrate the many religious and secular events that fall each December.
Spring Fling is an extended weekend full of activities.
University Day marks the anniversary of Chatham becoming a university and also is the traditional Bucket & Blossom event, when the entire campus community gathers to beautify the University grounds.
Closing Convocation is the traditional closing of the academic year when the undergraduate classes celebrate "Moving Up Day."
Why Purple & White?
The American and British Suffrage Movements of the late 19th and early 20th centuries adopted the colors green, purple and white to advance their causes. According to Mrs. Pethick-Lawrence, treasurer and co-editor of the weekly newspaper Votes for Women, "Purple as everyone knows is the royal colour. It stands for the royal blood that flows in the veins of every suffragette, the instinct of freedom and dignity...white stands for purity in private and public life...green is the colour of hope and the emblem of spring." (Spring 1908)
Many women's colleges of the period, including Pennsylvania Female College/Pennsylvania College for Women, adopted these colors as their own in testimony to women's suffrage. Hence, purple and white remain the colors of Chatham College for Women.


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Historic Charm in Downtown Jackson Hole
With the perfect blend of classic country inn style and modern facilities, The Wort Hotel is a unique Jackson Hole boutique hotel. Open since 1941, the hotel has a rich history of impeccable service and attention to detail in Wyoming. This luxury Jackson Hole hotel offers year-round fun, from skiing to hiking, as well as close proximity to Yellowstone and Grand Teton National Parks. Enjoy an unforgettable vacation at The Wort Hotel.
Gold and Platinum iPrefer members receive a bottle of wine when booking here or through iPrefer.com.


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The Sports Club
Hours of opening: 5 a.m. to 11 p.m.
5 a.m. to 10:30 p.m. Personal training and swimming lesson are available
6:30 a.m. to 9:30 p.m. Personal training is available
Racquet Sports Strategically positioned for refreshing sea breezes, the Sports Club's four floodlit tennis courts with superb surfaces promise exhilarating play, while the air-conditioned glass-backed squash court offers a cooler alternative. Internationally qualified coaching is available for all levels and ages for both tennis and squash enthusiasts. There are classes for ladies, mixed and children throughout the week. Competitions are periodically arranged for members.
Marina Facilities
Contact Us | Corporate Site | Careers
© 2014 The Ritz-Carlton Hotel Company, L.L.C. All rights reserved.
Downloadable directories in English, Português (Brasil), Русский, Español
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| 日本語 | 中文


text:
State Library
State Library |
Reference Services
Phone: (573) 751-3615
E-Mail: email@example.com
MoDOT Transportation Library
A Unique Partnership
As part of a joint agreement between the Missouri Department of Transportation and the Missouri State Library, Reference Services hosts the MoDOT Library. A collection of over 12,500 print and digital items, this resource provides research assistance to transportation employees, researchers, and the public.
Search MoDOT Catalog
State Research
Recently published Missouri transportation research is available on the MoDOT website in the Innovation and Market Research Libraries. The Innovation Library focuses on core engineering and technical topics while the Market Research Library emphasizes public opinion, customer satisfaction, and quality assessment.
Available Resources
Supplementing the State Library's collection, MoDOT has provided several major resources for use. These include:
- ASCE Research Library
A comprehensive online tool for locating articles of interest across all disciplines of civil engineering.
- Custom Search
A custom Google search tool that limits returns to U.S. state departments of transportation.
- TRID Database
A public-domain, web-based version of the Transportation Research International Documentation (TRID) bibliographic database.
- TRT Thesaurus
An online thesaurus that can be used to improve the indexing and retrieval of transportation information.
- RiP Database
A database hosted by the Transportation Research Board containing over 12,100 current or recently completed transportation research projects.
Contact Information and Library Services
Customized literature searches and requests for item loans from other libraries are offered to state and MoDOT employees. Additional support for and training on transportation databases can also be arranged as-needed. All services are available largely due to the support of MoDOT's Department of Construction and Materials.
For more information please contact:
Renée McHenry, Librarian
600 W. Main St.
Jefferson City, MO 65101-1757


text:
Narrow your search
Today Google and LG announced that the Google TV operating system on LG's Google TVs would be updated to Jelly Bean in the third quarter of 2013.
The handset that grew out of Nokia's doomed MeeGo operating system is now shipping to these shores, if you pre-ordered, that is.
Customers who pre-ordered the handset early when it launched on the Google Play Store should be recieving them no later than April 15.
The shipping date of Apple's Mac Pro has been put back to February, so bad luck if you wanted one for Christmas.
You can now get your hands on the Samsung Galaxy NotePro, packing no less than twelve inches and eight cores.
A single high-speed Thunderbolt port can link to a lot of devices. CalDigit's docking station is designed to ease the cable hassles of taking your laptop with you.
The PlayStation 4's new DualShock 4 controller is reportedly shipping to lucky pre-orderers already -- weeks ahead of the console's launch.
LG and Google have tweaked the Nexus 5, with subtle changes fixing some hardware issues with the handset.
Apple's cut the time you'll be waiting if you want a new iPhone 5S in the UK, with the fingerprint-reading new blower shipped within 1-3 days.
The phones will apparently range in screen size from 4 inches to 5.2 inches.


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French Open decides not to reseed Rafael Nadal
According to French newspaper L'Equipe, French Open officials actually considered reseeding seven-time champion Rafael Nadal.
They thought about making him the tournament's top seed "as a token of appreciation" but have instead opted not to.
The tournament will stick to its traditional system of seeding players according to the ATP rankings as they sit on the Monday before the tournament, May 20.
,@chachristine reports French Open chief Gilbert Ysern says in L'Equipe event will follow ranking for seedings, not bump up #Nadal #tennis—
Christopher Clarey (@christophclarey) May 04, 2013
Nadal, who has dominated Roland Garros by winning seven of the last eight years, has seen his ranking slip to No. 5 after a seven-month absence because of a knee injury. Since his return in February, Nadal has made the final of all six tournaments he's played, winning four of them.
Reseeding Nadal as one of the top two seeds for the tournament would have ensured he would not meet last year's finalist, Novak Djokovic, before the final. Djokovic ended his eight-year reign in Monte Carlo last month. If Nadal cannot take back the No. 4 ranking over the next two weeks, he will go into Paris seeded fifth. That means he could face any of the top four seeds, which include Djokovic, Roger Federer, and Andy Murray, as early as the quarterfinals.


text: Menopause Webcast Menopause and Incontinence: Staying Dry, Comfortable and Confident Medically Reviewed by Ed Zimney, M.D. Print Email Tweet During menopause, you may have found that hot flashes and fatigue are joined by another, perhaps unexpected, symptom – urinary incontinence. What can you do? Join us as our expert guests explain what causes urinary incontinence during menopause and share strategies to help control it. We'll discuss the role played by changing hormone levels, treatments from medicines to exercises, and how to handle the practical realities of living with incontinence. Plus, we'll explore the emotional stress this common problem causes and how you can feel confident again. As always, our expert guests answer questions from the audience. Announcer: Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you. Now here's your host. Rick Turner: During menopause, you may find that hot flashes and fatigue are joined by another perhaps unexpected symptom, urinary incontinence. What can you do about it? Hello and welcome to our HealthTalk webcast, Menopause and Incontinence: Staying Dry, Comfortable and Confident. I'm your host, Rick Turner, and during the next hour, we will discuss the causes, symptoms and treatment of urinary incontinence during menopause. Joining us on the phone for this conversation is Dr. Susan A. Hobson, a private practice urogynecologist in Portland, Oregon. She also sees patients and is on the steering committee at the Providence Continence Center at Providence St. Vincent Medical Center in Portland, Oregon. Welcome to HealthTalk, Dr. Hobson. Dr. Susan A. Hobson: Thank you. Glad to be here.Rick: It's our pleasure. So, Dr. Hobson, how does menopause affect bladder control? What is the connection, as best we know? Dr. Hobson: Right. Well, we're finding out that the answer to that question is less clear than we had originally thought. For some time, we have known that estrogen is beneficial to the urinary tract and the muscles of the pelvic organs, and we had often thought that estrogen was going to play an important role in incontinence or in keeping continent.Rick: Yes.Dr. Hobson: But newer data is just not supporting that.Rick: So the lack of estrogen itself does not seem to be the problem, or do we know that either? Dr. Hobson: Well, what's interesting, it's difficult to ferret out the difference between the process of going through menopause and losing estrogen and the process of aging because both of those can be associated with urinary complaints.Rick: Right. So what sorts of ideas are there about what is actually causing incontinence in menopausal women? Dr. Hobson: Well, I think what you are asking truly are what are the causes of incontinence in general? Rick: Specifically during menopause or do we know? Dr. Hobson: During menopause. Again, I think that's the problem. We don't know what is specifically due to being in menopause with lack of estrogen versus what is just age-related change, or if it's the two together at the same time.Rick: So we don't know? Dr. Hobson: We don't know.Rick: So do we know if treating the symptoms with estrogen ever helps? Dr. Hobson: Well, there are two cases where we have definitely seen that it helps, and one is specific to people who have frequent urinary tract infections, especially more than three times a year. We consider that to be too frequent.Rick: Right. Dr. Hobson: And treatment of the tissues with estrogen can make them more resistant to infection. So we found that that's been very helpful.Rick: Okay.Dr. Hobson: And then some people with what we call irritative symptoms, so they have painful or a burning sensation with urination, or they complain they have to go too frequently or too urgently, those sometimes are helped with estrogen. Rick: Are there cases where treating the problem of incontinence with estrogen actually makes it worse? Dr. Hobson: There is not treating. There was some data with the WHI study, the large study that recently came out I think about eight years ago looking at using hormone replacement therapy, and that was specifically looking at cancer risk and breast cancer risk.Rick: Right.Dr. Hobson: But some of the data that they got out of that study afterwards actually made it look like it could have made incontinence slightly worse by adding back estrogen, and that's a very confusing finding to us based on what we know…Rick: …right…Dr. Hobson: …about the physiology. Rick: So, Dr. Hobson, how common a problem is this in menopausal women? How many are incontinent? Dr. Hobson: Yeah. An actual number I couldn't really say, and the reports vary somewhere between a quarter to a half of all women, depending on the age group and the setting. And then the other fact to think about is that it's so underreported.Rick: That's what I was going to ask.Dr. Hobson: People don't like to talk about it, so an actual number is going to be hard to actually get at.Rick: Sure. A lot of symptoms that come with menopause, the hot flashes and things like this, are often temporary, and they eventually subside. Is incontinence associated with menopause in that same category, or is it more enduring? Dr. Hobson: No, it tends to be more enduring. Incontinence can be temporary if it's due to a factor that's easily treated such as an infection or irritation of the bladder by diet or smoking. But those bladder issues that are related to just normal, age-related changes, they don't tend to get better over time. They usually require some intervention to improve.Rick: You mentioned that this is probably underreported a lot, a lot of shame that goes with it, understandably, embarrassment. Talk to us about the emotional impact of bladder control problems on the people you see.Dr. Hobson: Well, for the people I see, I have to say there is quite a broad range of emotional impact sometimes varying from essentially none, just a bother, to severe depression and isolation. I think the crux of it is the person's severity of incontinence, how much they have deal with, but also their belief system.Rick: How so? Dr. Hobson: Well, some people think that bladder symptoms, they associate that with old age in a highly negative way, a loss of youth or a loss of health. It also affects their self-esteem with a partner if they are concerned about odor or leakage. The other thing is sometimes they just don't want to leave the house. They are afraid that they might have an odor or have a large loss there in public and be found out basically. And often they just become more increasingly isolated and depressed, and it rather spirals down even to the point where they won't seek medical help. Rick: So do you have any advice on maybe some effective strategies you have seen people employ to get over some of those emotional hurdles? Dr. Hobson: I think it's both relieving the incontinence but also changing our viewpoint. For me, as a culture and a community, we just need to re-educate ourselves with regard to the meaning of bladder symptoms as they reflect on our sense of self, just as we re-educated ourselves on how we feel about menopause and what reflection that has on our self-worth. So really the message needs to be that bladder symptoms are common, they are common at any age, even though they are more common as we get older, and they are a symptom of an underlying problem that can be addressed.Rick: Is this just a result of our puritanical roots, do you think, the reluctance to address issues like this? Dr. Hobson: I think it's that. I think it's overachievement. I think it's sometimes we are just very worried about the outside and superficial appearance.Rick: Sure.Dr. Hobson: But what I try to tell my patients that, I mean, this is difficult. We have Kleenex in the room always because there are some tears that comes with this sometimes. But this is no different than poor eyesight. It occurs at any age, but needing reading glasses is more common as we get older, and we get glasses. We don't stop reading. We don't feel ashamed that we don't have good eyesight, and we just need to reset how we think about these issues.Rick: Yes. So in your opinion, Dr. Hobson, when should a woman see a doctor about urinary incontinence? And what kind of doctor do you recommend she see? Dr. Hobson: Actually, I think a woman should see a doctor before incontinence because truthfully there are some proactive interventions women can do before the onset of incontinence. So with women and their OB/GYNs or their women health provider that they are usually having their annual exams with, they can discuss ways to prevent certain types of incontinence as well as other pelvic relaxation disorders, which often go together. At that time, Kegel exercises can be taught and assessed, and then that person can try to develop skills to prevent incontinence coming on.Rick: I see. So there are some proactive things, and we are going to be talking about some of the techniques, some of the lifestyle changes, but you say you can actually sort of head this off? Dr. Hobson: You can head that off, for several types of incontinence, absolutely. Rick: How is it typically diagnosed that someone indeed has an issue or has a problem with urinary incontinence? Is it based on just self-reporting? Dr. Hobson: It is typically based on self-reporting, although there will be times with people in certain situations where it's a loved one or a caregiver that brings that person in, and that's typically with people who are more infirmed or might have some dementia, but that's down the spectrum from this. This is typically a quality-of-life issue, and people come in when they have decided it's affecting their quality of life too much, as long as they don't get too isolated and depressed to do something about it. But I wanted to follow up your other question with when to see a doctor. And again I think it's important to say that anytime a woman feels that anything is significantly out of the ordinary that's the time to see a physician. It may not be the time to act on the problem, but at least to go in and get some information.Rick: Sure.Dr. Hobson: And I think that there is a very strong message that I want to give out, which is that in some cases urinary symptoms, especially urgency, frequency, incontinence or difficulty passing urine can be due to a more serious underlying problem, and we don't want to just automatically chalk it up to age-related changes. You really need to see a physician and make sure that there is not something more serious going on. Rick: Yes. What is a voiding diary? Dr. Hobson: So voiding is our technical term for emptying the bladder, and a voiding diary is a way to look at somebody's bladder habits. So we ask the person to collect some information for us. We ask them to collect information on how much they drink and what it is and at the times they drink it, and then they also keep track of every time they go to the bathroom and how much they went at a time and actually measuring that amount. That can tell us how well the bladder stores urine. If you are going to the bathroom with tiny, tiny amounts each time, that gives us a lot of information.Rick: Right.Dr. Hobson: It is also is very helpful in telling us when you leaked, what was happening? So was it related to a cough and sneeze? Did you have a very strong urge, you didn't make it to the restroom in time? Rick: Right. Dr. Hobson: And then finally it also can help us assess how much are you drinking? Sometimes bladder-related complaints are really related to overdrinking, taking in too much fluid, and that's a really easy thing to identify from that bladder diary or voiding diary.Rick: We have certainly received a mantra in recent years, haven't we, about drinking a lot of water? Dr. Hobson: Absolutely. And I think as typical Americans we have tried to overachieve on that and have really made our bodies work to get rid of extra water.Rick: More must be better, right? Dr. Hobson: More must be better. Rick: Can you explain for us, Dr. Hobson, the types of bladder control problems and incontinence that women can develop after menopause? Dr. Hobson: Yeah. Well, the two most common, I will list the two most common first. And the first is stress incontinence. The word "stress" is really referring to a physical stress, and that's where the seal, the closure to the bladder, to the outside world, which used to hold tight when you jumped rope or coughed or sneezed or laughed, it's now weak, and it allows urine to slip past with each cough or jump. The other type that's most common is urge incontinence, that, "Ah, I've got to get there right now," and the urine stream starts before you are actually sitting on the toilet. And then third, you can have both of those at the same time.Rick: Okay. And how about something called dysuria? What is that? Dr. Hobson: Dysuria really refers to a painful sensation at the time of urination. And true dysuria is irritation of the urethra that you are sensing as the urine passes by. Sometimes that can actually be related to lack of estrogen, and the tissues just become so thin and sensitive that it elicits pain, and just treating with estrogen can take that away.Rick: And then there is something called nocturia, which seems related to nighttime? Dr. Hobson: Yes. This is common as we get older as well. So nocturia is nighttime voiding. In its simplest form, it's the number of times one goes to the bathroom after going to sleep for the night and before waking for the day.Rick: Right. Dr. Hobson: But it doesn't really refer to the dog woke you up and you went to the bathroom. It's really how many times your bladder tells you to get up during the night to empty. This can just actually be caused by the fact that we are aging because our kidney doesn't hold on to water at night as well as it used to. Usually, it will concentrate the urine so that we can sleep, and that's why your first urine is so concentrated. But as we get older, the kidney doesn't do that as well. And the first step to try and improve this is just decreasing your drinking three to four hours before bedtime so that your kidney can get rid of all that water before you go to bed.Rick: Right. And you mentioned you can have more than one type of syndrome or incontinence at the same time? Dr. Hobson: Absolutely, yes. It's fairly common. Rick: So menopause itself may not be the driving force, the reason for urinary incontinence. What other causes besides aging or menopause can bring on these symptoms? Dr. Hobson: Well, one of the things that we absolutely know can bring it on is anything that weakens the pelvic floor, so childbirth, chronic cough, excessive weight, even extremely jarring sports activities are common, and that typically leads to some stress incontinence. And then age alone puts us at risk to have overactive bladder symptoms, and we just don't know why. But diet and pelvic muscle pain and just poor bladder habits also can lead to urinary incontinence.Rick: You said it's also possible that they could be indicators of something more serious going on. What about infections? Dr. Hobson: Absolutely. There are enough women who come in with just kind of vague urgency frequency for maybe the last three, four, five, six months, and we find an underlying infection. They just have a low-level infection.Rick: And then in terms of other things that might be causing these symptoms, diabetes, is that a factor? Dr. Hobson: Right. Diabetes, stroke, multiple sclerosis, all of those can be causes. And then most importantly, although it's less frequent, is cancer of the bladder, and that's very important to know that that can be a cause.Rick: And how about side effects of medications, can they bring on these same symptoms? Dr. Hobson: They can. I guess what I would say is one of the more common side effects of medication causing leakage are sedating medications.Rick: Sedating? Dr. Hobson: Yes. So when people are sleeping, they don't wake up until their bladder is very, very full, and they can have leakage just because they didn't have enough time to get the signal and get to the bathroom. And that brings up actually just one more type of leakage I didn't talk about, which is kind of what we call a functional leakage. It's basically when there is a presence of too many obstacles between you and the bathroom, such as people with highly regulated jobs and bathroom breaks or those who need assistance to get to the bathroom and do not have it or maybe those with arthritis or complicated clothing fasteners that they just can't get undressed in a timely fashion. Rick: Back to medications for just a moment, are incontinence or leaking problems common side effects of some more common drugs, such as blood pressure medications or heart medications, those sorts of things? Dr. Hobson: I don't see that. I have not seen that. I don't know if there is literature about that.Rick: Okay. Fair enough. So once it's been diagnosed, let's talk about how urinary incontinence is often treated. Can you give us an overview, Dr. Hobson?Dr. Hobson: I kind of like to categorize it into three major categories.Rick: Okay.Dr. Hobson: One would be behavioral changes. So you might have a change in diet or voiding or drinking habits like we talked about, timed voiding or increasing the muscular health through exercise, doing Kegels. The next category would be medications to either decrease overactive bladder symptoms or might increase the strength of that bladder seal to keep you from leaking. And then structural approaches, and basically those are trying to re-establish the support of the strength of the seal to the bladder, that can be a device that's something that fits in the vagina or a surgical approach. Rick: Okay. Well, let's go into these in depth then. Let's start with lifestyle changes. What sort of dietary changes first of all can one make? You mentioned we often drink too much as one of the causes of this problem.Dr. Hobson: Right. So, exactly, that's why the voiding diary becomes so important to understanding that. So there can be overdrinking and people having to just get rid of all that excess water. And then there are available lists of bladder irritants, things in our diet that can affect the bladder's activity.Rick: Make it more sensitive? Dr. Hobson: That make it more sensitive or actually irritate it and make it want to empty more often or urgently, and very commonly caffeine or alcohol or carbonation can even increase those symptoms or even be the sole cause of those symptoms.Rick: What about acidic juices, I understand those are helpful in preventing urinary tract infections, but can they also be irritants? Dr. Hobson: Yeah. That's kind of a trick, isn't it? Rick: Yeah.Dr. Hobson: No, absolutely. Cranberry juice is acidic, that helps decrease the growth of bacteria, but it can be irritating to the bladder lining. So it's a bit of a fine line. Smoking can also be a bladder irritant as well.Rick: Smoking. Okay. Another good reason to quit.Dr. Hobson: Exactly.Rick: And is weight a factor? Does extra weight bring on more bladder control problems? Dr. Hobson: Absolutely, yes. There are some very good studies showing that large losses of weight of people who are very obese, but even small losses such as 15 pounds can decrease people's complaint of stress incontinence – not so much the other types but generally the stress incontinence.Rick: Okay. And in terms of liquid consumption, if people want to cut back and maybe get a more balanced level in their body, how do they know what's appropriate? You don't want to take in too little liquid, right? Dr. Hobson: No, that's absolutely right. You don't want to take in too little. If you don't have a medical problem and your physician is not having you watch your liquid or water intake, then a general rule of thumb is when your urine is a light yellow, if it is clear, that's your body trying to get rid of pure water. And if it's a darker yellow or it's an amber, it's saying, you need a little bit more water.Rick: It's too concentrated.Dr. Hobson: In your system, it's too concentrated. And concentrated urine can also be irritating to the bladder or the external tissue.Rick: So just drink when you are thirsty? Dr. Hobson: Well, now, that I would say except if you drink when you are thirsty but you are consuming three liters of water, you might want to see a doctor because that could be an indication of diabetes or some other problem.Rick: Right. Good point. Okay. We are going to get to some of those other lifestyle changes and possible surgeries and medical treatments and all of those things. Dr. Hobson, what exercises, moving on to that topic, exercises are helpful for treating incontinence? Dr. Hobson: I think general exercise has been shown in and of itself to be helpful, but that can be difficult because people often complain of leakage with exercise. So specific exercises to decrease incontinence would be the Kegel exercise, and many people have heard about that.Rick: Yes.Dr. Hobson: The action of the Kegel exercise is basically what one does when they try to stop gas from passing or urine from passing? Rick: Okay.Dr. Hobson: And if a woman will repeat that activity by tightening those muscles and trying to hold it for 10 seconds 10 times in a row three times a day is just kind of a general recommendation. Some people will definitely need the intervention of a physical therapist, the guidance to be able to be successful with exercises, but certainly trying them first on your own at home is very, very appropriate.Rick: Okay. Can someone actually train their bladder to hold more urine? Dr. Hobson: Absolutely. So there are some bladders that this won't work with, but it's a good initial step to see if maybe you are just listening to your bladder with each little murmur and not asking it to wait long enough. And so what people can do is you just try to set a goal. So if you know that you go to the bathroom about every hour, hour and a half, the next time you get the sensation see if you can wait an extra 15 minutes, and then just keep progressively trying to do that. And there are certainly going to be people where that will not be effective, but that's giving us good information if it's not. Rick: That's interesting. I also understand that you can use biofeedback as part of the treatment. How does that work? Dr. Hobson: Now, biofeedback is a fun term. It's a term that really just describes an outside way of measuring a physical activity. Kind of an easy example of this is driving. If you feel the pressure of your foot stepping on the gas, and the car moves, and it's the movement of the car that tells you if you are stepping too hard or too soft. Rick: Okay.Dr. Hobson: Yeah. So pelvic floor biofeedback is kind of the same way. There is a sensing device essentially shaped like a tampon that sits in the vagina, and when you squeeze the appropriate muscles, it gives you a signal. So for people who have difficulty finding those muscles or trying not to use other muscles in the body at the same time, it's very, very helpful in kind of being a self-coach so they can assess how well they are doing.Rick: So in trying these different lifestyle and exercise and dietary approaches, Dr. Hobson, how long should someone give them? How long would they normally take to effect a change before you would want to consider something else? Dr. Hobson: Again going back, I think it's important that when you start trying those things you have already ruled out that there is nothing serious going on. Once trying them, I would say at least one to two months of really feeling like you have consistently tried it, not just on the weekends. And if that doesn't work, we do know success is greater for some people if they use a pelvic floor physical therapist to coach them through and to guide them and kind of reward them for making successes.Rick: Yes. Moving on to something slightly different, I have also heard that electrical stimulation of the pelvic muscles is sometimes used as a treatment for this. What type of bladder problem would that be appropriate for? Dr. Hobson: That is appropriate for stress incontinence, for the most part.Rick: Okay.Dr. Hobson: Using E-stim helps recruit muscles that a person is having difficulty recruiting themselves, and that electrical stimulation can kind of add more bang to your buck when you try to do that squeeze.Rick: So can you train the muscles using that? Dr. Hobson: Right. So you can train the muscles using that and help to increase the benefits.Rick: Okay.Dr. Hobson: So that's typically though for people with muscles that are in pretty seriously bad shape.Rick: Right.Dr. Hobson: The other time it is used is for pain syndrome, but that's used in a different way.Rick: Okay.Dr. Hobson: Although pain syndrome can be associated with bladder urgency and frequency, so it may come up in that instance. Rick: All right. Well, let's move on then to the topic of medications that are used to treat incontinence. What's typically used? Dr. Hobson: Well, the typical use of medication is for people with overactive bladder with or without leaking, and those belong to the group called anti-cholinergic. Rick: I have heard that term. What does that mean? Dr. Hobson: Say that again now? Rick: What does that term mean? Because I have heard it a lot on other things, anti-cholinergic.Dr. Hobson: It's the nerve message to the muscle to cause it to contract, and it kind of blocks that signaling pathway.Rick: Oh, I see.Dr. Hobson: So it works against that cholinergic signaling pathway to decrease the muscle contractions and trying to decrease dysfunctional muscle contractions, although it can cause functional muscle not to work so well. So people who already have difficulty emptying their bladders may not do well with those medications because they have more difficulty. Rick: And what are the typical medications in that category? Dr. Hobson: So the ones that most people have heard about would be Ditropan (oxybutynin), Detrol (tolterodine), oxybutynin and those types. And there are about eight more newer ones that have come down the pike, and for some people they work better, and some people they don't.Rick: Are there other common side effects people should be aware of? Dr. Hobson: Right. So the most common side effect would be dry mouth and constipation. Sometimes they can actually affect your ability to read close up, but that's just temporary while you are using the medication.Rick: Okay.Dr. Hobson: And then there are other people who have different individual side effects. One of the most important things though is to know that a person doesn't have the most serious kind of glaucoma, the closed angle glaucoma. Those people should not use those medications. Rick: I see a note about Detrol causing hallucinations in children and older adults. What do you know about that? Dr. Hobson: Yes. So that anti-cholinergic effect, which is good for slowing down the bladder muscle activity, can cross the blood-brain barrier and have people have some difficulty with mentation or orientation. And it's not that common, but it's more apt to happen in susceptible groups, like the pediatric groups or the older geriatric groups.Rick: Okay.Dr. Hobson: So it is something definitely to look for in all patients when you are starting medications, but especially our older ladies. Rick: I also understand that anti-depressants are often used to treat this. Why is that? Dr. Hobson: Anti-depressants aren't typically used for overactive bladder, but it depends on the one you are talking about. So do you have any specific names? Rick: Well, I see duloxetine. Is that how it is pronounced? Dr. Hobson: Okay. So you're right. So duloxetine has actually been tried for stress incontinence. It's the one medication which is thought to be helpful in tightening the urethral sphincter to decrease stress incontinence but not for overactive bladder. Rick: What about imipramine? Dr. Hobson: So imipramine was one of the first anti-cholinergics. I'm sorry. I often forget that it was originally an anti-depressant. Rick: Okay. Dr. Hobson: But it is not so commonly used for that now. Rick: Interesting. So those are used. And was that discovered just as a side effect of those drugs if they were originally designed as anti-depressants? Dr. Hobson: I think imipramine was a discovery. Duloxetine, I think that they theorized that it would work that way and found that it did somewhat. Rick: I see. Yes. Moving on then with some devices that can be inserted into the body to help with urinary incontinence, what's available? Dr. Hobson: The most common thing is a device called a pessary. A pessary is a soft silicone device that can be placed in the vagina, and it's usually shaped like a diaphragm, but it has a little bit more tensile strength. So it actually can push against the urethra and give a little extra support and in that way kind of restore that natural closure to the urethra so when you cough and sneeze you don't get that leakage. Rick: I see. And there is something called a urethral insert? Dr. Hobson: Yes. There are, I think, several styles of this. It's an insert that basically is either a deflatable balloon or a mineral oil-filled plug that can be just passed into the urethra and then held there in place until at which time you decide you want to empty. And so those are good again for stress incontinence but probably not for people who have leakage throughout the day but people who have leakage with very specific activities. For instance, a runner who might just want to use that device while they run… Rick: Right. Dr. Hobson: …and take it out.Rick: Okay. And then there is something called an external urethral barrier. What is that? Dr. Hobson: I have to admit I am less familiar with that, but it works within the same principle without actually going into the urethra and bladder like the plugs do. Rick: Okay. Then moving on to the issue of surgery, when is surgery a good option for treating urinary incontinence? Dr. Hobson: Surgery is really just another way to try to restore the function of that seal, that mechanism to keep urine in the bladder and not leaking outside. And I think when all other conservative measures, exercise, have failed or when a person has either tried a pessary or just knows for themself that a pessary is not a good option, then surgery is a good option. Rick: So you view it as a last resort? Dr. Hobson: It's a last resort mainly because it just has higher risk, and if somebody can get away with something smaller, there really is no risk to that. Rick: So we mentioned there are many different types of incontinence. I would suppose there are different types of surgeries to treat them. Do they all have different goals? Dr. Hobson: They have the same goal. They all want to help restore that closure valve on the bladder, which is basically the urethra, so they all support the urethra helping it to close itself when you have a cough or a sneeze the way that it used to. And they can either do that either by using your own tissue to kind of elevate the urethra back into position or placing a mesh or a piece of your own tissue in that position to resupport the urethra.Rick: And what is the success rate of surgery for this problem? Dr. Hobson: It depends on the paper that you are reading. I would say that – and it depends on the procedure – the sling procedures have reported anywhere from a 65 to 90 percent success rate.Rick: Okay. And again, what is a sling procedure? Dr. Hobson: So the sling is the procedure where we pass either a mesh, a woven piece of synthetic material behind the urethra, or your own tissue, which would be a piece of your fascia, behind the urethra and basically supporting the urethra. And it basically kind of looks like a sling because it's in a U-shaped conformation kind of holding up the urethra. Rick: I see. Okay. And then what about with other types of surgeries, how successful are they? Dr. Hobson: They are about as successful, but they have different side effects. I'd say all of our procedures are somewhere between the 65 to 90 percent, depending on the series and depending on the patients' initial complaints.Rick: And would that be a permanent solution? Dr. Hobson: It's meant to be permanent, but those are the failures that come up are people where it does not remain permanent for them. And they can either be redone, or they can be augmented with other types of procedures.Rick: Okay. So we have covered lifestyle changes, diet and exercise and those sorts of things, exercise included. We have looked at inserts. We have talked about surgery. Are there any other types of treatments we should know about, Dr. Hobson? Dr. Hobson: Well, in the overactive bladder group besides medication and physical therapy, there are two procedures we're using for people who just really don't respond to any of those interventions. And one is called InterStim. It's basically an implantable device that stimulates the nerves leading to the bladder to try to relax them, which sounds counterintuitive.Rick: Yes.Dr. Hobson: But it basically can do what those medications do but just through a different mechanism. Rick: Okay. Dr. Hobson: We use it on the most difficult of difficult patients, and it has about a 50 percent success rate on those, but those are the most difficult patients. Rick: Okay. Is it a little battery-charged thing? Dr. Hobson: It's very similar to a pacemaker.Rick: A pacemaker. Right.Dr. Hobson: Yes. And if it's successful, it's implanted permanently. Rick: Okay. Dr. Hobson: And the other new treatment that we have is Botox, botulinum toxin. Rick: Yes. Dr. Hobson: Injection into the bladder wall. Likewise, it will quiet those bladder muscles for those people who don't respond to medication or other interventions. Rick: And how long does that last? Dr. Hobson: We are still finding out. It's fairly new. We are looking at somewhere on the order to two to five years. We will just have to see. Rick: Wow. And then I know there are a lot of over-the-counter products available to help women stay comfortable and dry. Can you tell us about some of the better ones in your experience? Dr. Hobson: It's very specific to the person. Rick: Okay.Dr. Hobson: I don't have like a list of the best. I think it's really what works for each person. Some people just want a little menstrual pad, mini-pad because they really don't want the bulk, and they don't have large losses.Rick: Okay.Dr. Hobson: And others really need to be prepared for a huge overwhelming loss so that their clothing doesn't get wet, and that's going to be the larger garments.Rick: Sure. Is there a clearinghouse for information about that sort of thing, the range of options available? How can women find out? Dr. Hobson: Yeah. Let's see. What's the best? I would say the International Continence Society Web site has a good patient site, the American Urogynecologic Association site. Rick: Do you have a Web site at the tip of your tongue? Dr. Hobson: Well, the augs Web site, so that's www.augs.org. Rick: All right. Dr. Hobson: And that's our American Urogynecologic Society, and they will have some good, very good patient information there as well. Rick: Okay. Dr. Hobson, let's go to the questions for you. The first one comes from Tyngsborough, Massachusetts, and this listener writes, "Have you any suggestions on how to remember to do the Kegel exercises for the pelvic floor muscles?" A little string on your finger or what? Dr. Hobson: Yeah. Well, that's one thing. Sometimes people pick something that's regular throughout the day. Like if for that three times a day routine, before each meal or after each meal. I have one woman who Kegeled at every stoplight.Rick: Depending on your city, that could be a lot.Dr. Hobson: You don't want to overdo it.Rick: Right.Dr. Hobson: Sometimes people just have a little code to themselves, the Special K on the box. That's the Special K, right? You can put it somewhere. So really it's like anything. Before it becomes routine, we just need little reminders, and just to try to set something up that says, "Okay, this is when I do this."Rick: Okay. And again you mentioned it earlier, what is a good regimen for doing Kegels? Dr. Hobson: Right. So when you first try it, try to bring that muscle up, tighten it up and hold that as close as you can to 10 seconds, and initially it's not going to probably be 10 seconds. Rick: Uh-huh. Dr. Hobson: But try, 10 times, three times a day. Rick: Okay. Next question comes to us from San Diego, California, "I have been doing my Kegel exercises," we are on the Kegel topic here, "for incontinence, but they are not helping. What should I do?" What's next? Dr. Hobson: Yes. Well, I think this is the point at which to seek somebody's advice to see a physician. So the physician may have you see a physical therapist but may have some – if you are self-diagnosed – additional information that you didn't know. Rick: And you said typically with things like this, you want to give it a couple months? Dr. Hobson: I recommend a couple months of really feeling like you have done it routinely. It's similar to if you are taking up exercising at the gym. Your muscles are sore the first day, but you don't really see a change in definition or size for a couple months. Rick: Yeah. It does take time. Dr. Hobson: And it is the same type of muscle. It is skeletal muscle, and you build it the same way. Rick: Okay. Redmond, Washington sends our next question, "Is there any way to prevent incontinence before it starts?" Something we talked about during the program. I think we can go over that again. Dr. Hobson: Right. So again, this can be introduced as early as adolescence. Certainly women of childbearing age and before pregnancy to just ask your women's health provider that exact same question, and usually what they will do is go over the Kegel exercise and when and how long to do it. And that is the main intervention.Rick: That is the main one. Is there a specific age at which people should consider that? Dr. Hobson: It's hard to imagine it being too young, but I would say certainly by the time people are in their early 20s it would be great to add to their armament of other exercises.Rick: And you say it's often in connection with pregnancy and childbirth that problems develop? Dr. Hobson: Right. And I think that that's what spurs providers on to talk about this is in anticipation of problems at the time of delivery or afterwards. But we need to do better at having people even before they are considering pregnancy to be getting those muscles on the radar to stay strong.Rick: Yes. Tuned up.Dr. Hobson: Yes. Rick: Forest City, Pennsylvania, is the source of the next e-mail, "I have found that using pads works okay for me in dealing with minor leaks. I have not been to the doctor, and frankly I'm embarrassed. Is it possible that the situation will worsen if I don't act?" Dr. Hobson: So it certainly is possible. One thing to say here is that what we know about her is that she leaks small amounts sometimes, and she needs a pad, but we don't know why she leaks. Is it with an urge, like a sudden, overwhelming, "I can't get to the bathroom?" Or is it just with a cough or a sneeze? The cough or the sneeze issue, yes, it does likely get worse if you do nothing, but there is less concern that there can be an underlying problem. And I don't know the person's age, but given that they are listening to a menopause show they likely could be of the age where they are at risk of a more serious problem. Rick: Right. And you say it's with the cough or the sneeze that this problem might be occurring. Would that be the type of stress incontinence you described? Dr. Hobson: Exactly. That's right. Thank you. Rick: Okay. Let's go to Chicago, Illinois for the next question, "I have to get up to go to the bathroom two or three times every night. Is this normal, or should I be concerned?" Dr. Hobson: So two to three times a night still falls within the range of what we say is normal. I think what I would say to that person is if they never got up, and now suddenly they are getting up three times a night, that's a significant enough change to wonder what's going on. But if that's been their pattern, twice or three times for years and years, then likely they should not to be concerned in and of itself. Rick: Right. And again the typical way to address that issue, drink less water and other liquids consumed within what, four hours of bedtime? Dr. Hobson: Four to five hours is what I usually say. And the thing we don't know about her as well is does she go too often during the day, or is this just a nighttime issue? Because if it's just a nighttime issue, it is more likely to respond to things like fluid restriction earlier in the day, and there are some other maneuvers. If people tend towards having edema in their legs, if they lay down a couple of hours before bedtime and with their feet elevated, that can get that fluid back into the bloodstream and out of the body rather than having that happen during the night when you have to get up and actually empty your bladder. Rick: Oh, interesting. Okay. Let's go to Seattle, Washington next, "My main symptoms are pain and pressure during the night because when I am asleep I am not emptying my bladder as often, but I do have to get up at least twice during the night because the discomfort in my bladder wakes me up. During the day, it's not so bad, although I do go through phases of needing to go frequently. Sometimes it's hard to get the flow going, other times no problem. Any thoughts?" Dr. Hobson: Yeah. The two things that key in for me are the pain and pressure, and then sometimes it's hard to get the flow going.Rick: Yes.Dr. Hobson: Those two things make me wonder about this woman's pelvic floor, whether actually there is muscle dysfunction, spasm in those muscles in the pelvic floor that cause those muscles to be painful either when the bladder gets full or maybe with intercourse for this person. She didn't mention that.Rick: No. Dr. Hobson: And then during the day if those muscles are in spasm, they don't want to let the door open appropriately. So it can make it difficult to pass urine for that person. So she is an excellent candidate to be seen by a physician and likely a physical therapist. Rick: And muscle spasms, I don't know that we touched on those per se. Dr. Hobson: No, we didn't. The pelvic floor muscles are a bowl of muscles that support the pelvic organs. The Kegel exercises, the name, really refers to tightening those muscles. Those muscles are important for supporting the organs. They are important for trying to close off the valve when you don't want to go, but they have to relax for you to be able to empty your bowel or your bladder. Some people put their stress into those pelvic floor muscles, and they can get tight just like getting a knot in your back or your neck. Rick: Sure. Dr. Hobson: Or other people can have musculoskeletal issues that kind of change their body posture that puts too much stress on those muscles. And then those muscles can be dysfunctional where they are tight when they are not supposed to be, and they can't contract further because they are already maximally contracted. So people end up getting firm muscles that don't respond right. They don't get tighter when they don't want to leak, and they don't relax when they want to go to the bathroom. And they get painful whenever they are asked to do anything. Rick: I am curious about doing the Kegel exercises. Can those ever trigger a spasm? Dr. Hobson: Absolutely. And that unfortunately is what we also see in our American overachiever society is that if I say 10 seconds 10 times three times a day, there are going to be some people whose muscles aren't ready for that. Or there is going to be other people who say, "Well, that means a thousand three times a day will be better," and these people will likely get into muscle fatigue and pain just like if I did a thousand sit-ups tomorrow my stomach would be on fire. Rick: It would be protesting that, yes. Okay. Let's see. We have a question from Bremerton, Washington, "I seem to have lost the ability to know when I need to urinate. I just don't seem to feel the urge to pee very often. But I have noticed that when I have a hot flash, it seems to be linked with needing to pee. This seems really strange, but is it normal?" Dr. Hobson: No. Now, I am wondering if this person is equating hot flashes with actually getting sweaty and diaphoretic. When your bladder gets overextended, it activates other nerves in the autonomic system, and people get sweaty, and I am just wondering if her bladder is getting overdistended. Rick: So that could be confused with a hot flash? Dr. Hobson: Absolutely. Yeah. Rick: Okay. Let's see. Amherst, Massachusetts, "I am 52 years old, and I haven't had a period in two years. I get a sharp feeling in my urethra signaling that I should urinate soon. I only notice it when lying down, reclining or sitting. I guess it's urgency, but I can usually wait up to a half hour before actually emptying my bladder. There is usually at least a medium amount of urine coming out each time. I have no pain, no other symptoms of a urinary tract infection. Any ideas on what might be going wrong?" Dr. Hobson: That might be somebody who actually would respond to some topical estrogen. She might have some urethral irritation or sensitivity where she is just reinterpreting – or not reinterpreting – where the urethra is actually getting sensitized to the need to have to go to the bathroom. But there is not a real simple answer, and it would be very easy for somebody to just take a look over and make sure that nothing else is going on. Rick: Right. Something we obviously can't do in this setting here today. Dr. Hobson: Right. Rick: From Portland, Oregon, your town, "This just started a few months ago. I dream of peeing and forget that I'm dreaming, and a few times I have peed a few drops before waking up. Once I peed the bed thoroughly. What's going on?" Dr. Hobson: That's sometimes what children describe.Rick: Yes.Dr. Hobson: In an adult, we always have to wonder why the nervous system is not working the way it used to. In a kid, we can explain it as well. It's just the nervous system to the bladder hasn't quite developed. But if we then later kind of lose it and start having leakage during the night, that can sometimes be a sign of something underlying that needs to be investigated. Rick: Like what? Dr. Hobson: I am trying to think of the most useful way to say it, either spinal cord tethering or something at the level of the spinal cord. And then the other thing to consider is again if this person is just oversedated or overtired, where kind of like you make a story up about your alarm because you don't want to get up yet. Rick: Yes. Dr. Hobson: And then by the time you get up, you are a little late. Rick: Yes. Dr. Hobson: Well, the same thing might be happening with her bladder as well. So it really depends on if this is happening out of the blue or if she can explain it with increased fatigue or maybe a sedative. Rick: Right. But something is keeping that message that used to be there all the time from getting through? Dr. Hobson: Right. It's not waking. It's just kind of getting turned into a dream. Rick: Yeah. Interesting. Let's see. Let's go to California for the next question, "I don't mind getting older. I didn't mind it until the incontinence started. I feel like I'm losing my dignity, and I am very down about it. I am single. I am only 55. It's hard to feel like dating when I can't even control my bladder. What are your thoughts?" Dr. Hobson: Right. So this is not your fault. This is just something that has occurred with your body. You are just as youthful as you were the day before it started happening. It's just something that needs to be addressed, just like if you needed reading glasses. So it's just very, very important for this person to go, to move exactly past that recognition into the action mode. See somebody. See a doctor. See what's going on, get it fixed so you can just keep living. Rick: You talked about this earlier where we associate that problem, incontinence, leaking, with old age. Dr. Hobson: Absolutely. I mean, there are people who go into tears when they finally say, "This reminds me of my great-grandmother," or somebody that they think of that is very infirmed, much older who has lost control and not recognizing that there are many, many, many younger, functional people who have had the same problem. Rick: Yeah. We have a question from Oklahoma, "Can I become incontinent again after having a sling procedure? And how long does it take to recover from a sling procedure." That's something we talked about earlier. Dr. Hobson: Right. With every procedure that we do, there is a failure rate, a rate of people who either initially won't be cured, or they are cured, but then over time the results will diminish. Rick: Yes. Dr. Hobson: If that's happens, there certainly are things that can again be done, so it's not once and then that's it.Rick: That was your last chance.Dr. Hobson: Not at all. Rick: Good. Dr. Hobson: What was the second question? Rick: How long does it take to recover? Dr. Hobson: So there if you are only having a sling, and you and your physician choose what we call a minimally invasive sling, typically people go home the same day, and they are back to work, depending on their work, potentially over the weekend. Rick: Wow. Is it done arthroscopically with just a small incision, or laparoscopically or however it's described? Dr. Hobson: Right. Well, similarly. So we do use instruments to pass the sling through, and actually we are not watching our instrument as we do it. We just guide it. We know exactly where we are at. And then we look in the bladder with a cystoscope and make sure that we have not gotten into the wrong place. Through three tiny incisions, that mesh gets placed correctly and usually works very, very well. Rick: Okay. We have a question from Phoenix, "It started as a typical urinary tract infection, burning when going and the urge to go. I went to the doctor, got antibiotics, and that cleared up the infection. The test yesterday of urine showed all clear, bladder X-ray fine, kidneys fine, but now I am going on three weeks and I still have symptoms of the infection, uncomfortable when I go, and the worst is when I sit and even standing have the terrible urge to go. I have another doctor's appointment scheduled, but what do you think is going on?" Dr. Hobson: Well, sometimes it can be residual irritation of the bladder after the infection. I liken it to when you skin your knee, the cement is gone immediately, but the knee has to repair for quite some time afterwards. Rick: Yes. Dr. Hobson: And the bladder infection can be the same way. Once we have cleared the bacteria, there is still the injury to the bladder wall that has to heal. That's one possibility. Another possibility is that this person's infection has recurred or not been completely cleared in the first place. And then the third possibility is sometimes that irritation of the bladder is just the trigger that causes those pelvic floor muscles to respond inappropriately, and they then become the problem, pelvic floor spasms. Rick: Yeah. Dr. Hobson: But it's so important for that person to return and have them take a good look over her again. Rick: Yes. And you say if it's been successful with the treatment of the antibiotics and the infection was cleared, how long does it take for the bladder to recover from that injury, if you will? Dr. Hobson: Typically, people's symptoms, we know they are getting better because they are better within 24 to 48 hours. But I have had some people who have just minor residual discomfort for up to a week or two. Three weeks is a little unusual, so I would be looking at her urine again and looking at whether there is some other irritation to the bladder that's not related to that infection. Rick: Okay. We have time for one more question. It comes from New York, New York, "Will a pessary," which we mentioned earlier, "cause infections? And can I have sex with a pessary?" Dr. Hobson: The answer to the second part of that question is yes if it's the right shaped pessary. Rick: Okay. Dr. Hobson: So we have two shapes of pessary. One pessary is shaped like a diaphragm, and so you can infer that it is okay to use during intercourse. Rick: Right. Dr. Hobson: There are some pessaries that are placed for prolapse, and those are likely to be bulkier and not allow any other objects in the vagina. Rick: Can you request a certain type, or does it depend on what you need? Dr. Hobson: Yes. You and your physician actually really talk about what are we trying to achieve with this pessary? What is your lifestyle? What do you need out of it? If it's purely for stress incontinence, then it will overwhelmingly be the type that is of a shape that will allow for intercourse. It will be that round dish, diaphragm-type shape. Rick: Okay. And the first part of the question? Dr. Hobson: Infection. Rick: Yes. Dr. Hobson: So I should say no. People don't get true infections from having a pessary, but people will often get an overgrowth of the bacteria in the vagina they are not secreted and re-absorbed in the usual fashion, they can kind of collect around the device, and then bacteria can grow in that. And so they can get kind of a heavy discharge that maybe even might be malodorous, but speak to your physician about how that can be addressed. Rick: Okay. Fair enough. Dr. Hobson: Yeah. But true infections don't occur. Rick: Good. We are just about out of time with that. So before we let you go, Dr. Hobson, how about some final thoughts, what would you like to leave our listeners with today? Dr. Hobson: I think what I would like to say is that no matter what your problem is with incontinence or bladder issues, see a doctor. And if you don't feel like you get a good listening ear from the first doctor, see a second one. Just make sure that you don't get into the situation where you are feeling poorly, where it is affecting your life because there is no reason it should. We have so many ways to make all of this better. Rick: Great. Dr. Susan Hobson from Portland, Oregon, thanks very much for joining us for this hour. I have enjoyed it. Dr. Hobson: Oh, my pleasure. Thank you so much for the opportunity for education. Rick: Sure. And thank you for listening as well and all your great questions. From HealthTalk, I'm Rick Turner. Tweet Last Updated: 09/23/2008 This section created and produced exclusively by the editorial staff of HealthTalk. © 2009 EverydayHealth.com; all rights reserved. Next Article: Sign Up For Newsletters At Everyday Health »


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Profit warnings from Britain's listed companies fell dramatically in the second quarter, according to a new report, boosting hopes of strong U.K. growth figures for the second quarter.
Ernst and Young (EY) said 54 U.K.-listed companies warned over earnings in the second quarter – 25 percent fewer than in the first quarter.
The number of companies that issued profit warnings was the lowest since 2010, according to the report, when it was just 51.
(Read More: Forward guidance? Sterling could be about to fall)
Keith McGregor, EY's head of restructuring for Europe, Middle East and Africa, said the low number of profit warnings was a sign of growing confidence in Britain's economy.
"The U.K. recovery certainly appears more entrenched and better placed to ride out the aftershocks that have triggered sobering second half dips in economic activity in recent years," he said.
"A more benign economic climate should keep the number of profit warnings low, but below par growth will continue to create challenges."
(Read More: Don't panic! UK recovery is 'firmly entrenched')
EY's report comes ahead of the first estimate of U.K. gross domestic product (GDP) on Thursday, and follows a slew of better economic news which has led a number of organizations, including the International Monetary Fund, to upgrade their growth forecasts for the country.
Last week, analysts said strong retail sales and employment data boded well for U.K. GDP, which is expected to come in at around 0.6 percent quarter-on-quarter.
The retail and construction sectors in particular had shown signs of improvement in the second quarter, according to EY.
Just two retail companies issued profit warnings, the lowest since 2010, as British consumers got a boost from the strong employment figures and an improving housing market.
Meanwhile, three companies in the construction and materials sector warned over earnings – a slight rise from the first three months, but four fewer than the same period in 2012 when they equalled their credit-crunch high.
(Read More: Bank of England unites against QE under Carney)
Still, EY was cautious about the future, arguing that although the momentum should prevent a "summer setback," there were clouds on the horizon.
"The recovery is no stranger to false dawns and profit warnings have followed this pattern, dropping to historic lows, only to spike back up as recovery hopes are dashed," McGregor said.
"Domestic and external challenges look set to limit the rate of growth and the U.K. economy is still a long way short of its pre-crisis level of activity. It is a brighter outlook, but the recovery has a few years yet to run."
U.K. earnings season kicks off with a vengeance next week, with FTSE 100 stalwarts including GlaxoSmithKline, BT, Unilever and Pearson among the companies due to report.
-- By CNBC's Katrina Bishop. Follow her on Twitter @KatrinaBishop


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HEC Paris
Paris, France
HEC Paris Website
Virtual Tour of HEC
Paris, France
About HEC Paris
"HEC (Hautes Etudes Commerciales) Paris is considered to be one of the "four aces" in training the French elite. Unique to France, the "Grande Ecole" concept was introduced by Napoleon so that "the best and the brightest" could be channeled into his ministries, armies and engineering corps. HEC's School of Management is among the first business schools in Europe and the first in France to hold the Triple Crown Accreditation. HEC has a long-established tradition of welcoming international students to its lively and friendly campus: an ideal environment in which to live and learn for over 3500 students from 80 nationalities in our programs." HEC Paris
Note: Stern has established an UNDERGRADUATE exchange with HEC at the third year (or what they call "foundation" year) of their five-year program for top French students. The HEC five-year program consists of two year of rigorous study that some consider equivalent to the first two years of a bachelors program. This is is followed by an additional three-year program where students complete their bachelor studies and then commence their master level studies. HEC students earn a master's degree at the end of their five year program.
Term Dates
Students are offered the possibility of living on Campus by renting a room (415 €/month). This monthly charge covers the basic rent, cleaning, breakfast in the university restaurant. Refundable deposit: 400€ + 130€ processing fee.
Approximate Living Expenses
Language of Instruction
English or French
Student Services


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April 21, 2014 | Baseball
The Crusaders waited out a 33-minute rain delay to defeat the Kalamazoo Hornets 10-3 at Emory G. Bauer Field Monday. Jeff Edwards, Chris Manning, Karch Kowalczyk, Grant Yoder, and Mark Johnson each had two hits at the plate as Drew Hasler threw five shutout innings to earn his second win of the season.
April 21, 2014 | Softball
After three straight weeks of nothing but home games, the Valparaiso softball team plays six games in three different locations this week. A non-league doubleheader at Western Illinois and a single game at nationally-ranked Notre Dame set the Crusaders up for a huge Horizon League series this weekend at Wright State.
April 21, 2014 | Baseball
Senior right-hander shares the honor with UWM's Cody Peterson. Webb threw a two-hit shutout versus the Panthers on Thursday, walking one and striking out a career-high eight batters.
April 20, 2014 | Men's Golf
Competing in its final tournament prior to the 2014 Horizon League Championship, the Valparaiso men's golf team placed 12th on Sunday at the Wolfpack Spring Open, hosted by North Carolina State in Raleigh, N.C.
April 19, 2014 | Men's Track & Field
On Saturday, the Crusader men traveled to Chicago, Ill. to compete in the DePaul Relays. Valparaiso finished second overall with 191 total points. Antwon Hatchett and Jacob Frey led the Crusaders with first-place finishes in their respective events.
April 19, 2014 | Women's Track & Field
On Saturday, the Crusader women traveled to Chicago, Ill. to compete in the DePaul Relays. The relays featured athletics from DePaul, Northern Illinois, UIC, and Northwestern. Behind a handful of top-five finishes, Valparaiso took third overall with 82 points. Brook Hinstorff and Jazmin Taylor led the Crusaders on the day with first and second place finishes in their respective events.
April 19, 2014 | Men's Tennis
Crusaders conclude the regular season 18-8 overall, 3-3 in Horizon League play after Cleveland State took a 5-2 decision Saturday at the Valpo Tennis Complex. The Brown and Gold wrapped up the 4th overall seed in the process.
April 19, 2014 | Softball
On a Senior Day where runs were at a premium at the Valparaiso University Softball Field, Valparaiso earned a 2-1 win in the first game of the doubleheader against Oakland before falling in extra innings for the first time this season, losing the nightcap 4-2 in eight innings.


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Student organizations for Civil, Construction and Environmental students:
For a complete guide to all student organizations at Marquette, check out the university student organizations or engineering student organizations list.
The Career Services Center assists students seeking internships, graduating seniors looking for entry-level positions and alumni looking for new or different career positions.
Cooperative education (co-op) is a program combining academic study and practical work experience — a learning and training partnership between Marquette, employer and student — beneficial to all participants. Co-op provides students with hands-on, career-related work experience and the opportunity to develop professionally and academically.
The Office of Student Educational Services helps students with their academic programs. Tutoring services are provided free of charge on a drop-in or group-session basis in a variety of subjects. Other services include workshops on time management, test taking and study skills and disability support services.
Marquette's Student Employment Service in the Office of Student Financial Aid helps students seeking part-time employment on and off campus. All Marquette students are welcome to use the Student Employment Service.