Prospective observational study of the impact of vaginal surgery (pelvic organ prolapse with or without urinary incontinence) on female sexual function

INTRODUCTION AND HYPOTHESIS

There is a difference of opinion in the literature as to whether pelvic organ prolapse (POP) is a direct cause of female sexual dysfunction (FSD). Sexual function in women is negatively impacted by the presence of urinary symptoms. Thus, sexual dysfunction (SD) might be improved, unchanged, or worsened by pelvic floor surgery.

METHODS

In this study, we observed SD and impact of surgical intervention on female sexual function (FSF) using a validated Prolapse/Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12) in women undergoing surgery for POP with or without urinary incontinence. Two hundred women were recruited and followed up at 6 and 12 months postoperatively.

RESULTS

Sexual function (SF) as measured by the PISQ-12 improved after surgery irrespective of the nature of surgery or the patient's past gynaecology history. Improvement in SF was seen by 6 months (97 patients) postsurgery (P < 0.05), after which (at 12 months; 80 patients) no further change was observed. Improved SF was associated with better patient satisfaction postoperatively.

CONCLUSIONS

Sexual function improved in women following surgery for POP with or withour urinary incontinence, irrespective of the nature of surgery and the patient's past gynecologic history. Results of this study will assist when counselling women with POP with or without urinary incontinence regarding treatment options.

Abdominal massage for neurogenic bowel dysfunction in people with multiple sclerosis (AMBER - Abdominal Massage for Bowel Dysfunction Effectiveness Research): study protocol for a randomised controlled trial

BACKGROUND

Multiple sclerosis (MS) is a life-long condition primarily affecting younger adults. Neurogenic bowel dysfunction (NBD) occurs in 50-80% of these patients and is the term used to describe constipation and faecal incontinence, which often co-exist. Data from a pilot study suggested feasibility of using abdominal massage for the relief of constipation, but the effectiveness remains uncertain.

METHODS/DESIGN

This is a multi-centred patient randomised superiority trial comparing an experimental strategy of once daily abdominal massage for 6 weeks against a control strategy of no massage in people with MS who have stated that their constipation is bothersome. The primary outcome is the Neurogenic Bowel Dysfunction Score at 24 weeks. Both groups will receive optimised advice plus the MS Society booklet on bowel management in MS, and will continue to receive usual care. Participants and their clinicians will not be blinded to the allocated intervention. Outcome measures are primarily self-reported and submitted anonymously. Central trial staff who will manage and analyse the trial data will be unaware of participant allocations. Analysis will follow intention-to-treat principles.

DISCUSSION

This pragmatic randomised controlled trial will demonstrate if abdominal massage is an effective, cost-effective and viable addition to the treatment of NBD in people with MS.

TRIAL REGISTRATION

ClinicalTrials.gov, ISRCTN85007023 . Registered on 10 June 2014.

Can incontinence be cured? A systematic review of cure rates

BACKGROUND

Incontinence constitutes a major health problem affecting millions of people worldwide. The present study aims to assess cure rates from treating urinary (UI) or fecal incontinence (FI) and the number of people who may remain dependent on containment strategies.

METHODS

Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and PEDro were searched from January 2005 to June 2015. Supplementary searches included conference abstracts and trials registers (2013-2015). Included studies had patients ≥ 18 years with UI or FI, reported treatment cure or success rates, had ≥ 50 patients treated with any intervention recognized in international guideline algorithms, a follow-up ≥ 3 months, and were published from 2005 onwards. Title and abstract screening, full paper screening, data extraction and risk-of-bias assessment were performed independently by two reviewers. Disagreements were resolved through discussion or referral to a third reviewer where necessary. A narrative summary of included studies is presented.

RESULTS

Most evidence was found for UI: Surgical interventions for stress UI showed a median cure rate of 82.3% (interquartile range (IQR), 72-89.5%); people with urgency UI were mostly treated using medications (median cure rate for antimuscarinics = 49%; IQR, 35.6-58%). Pelvic floor muscle training and bulking agents showed lower cure rates for UI. Sacral neuromodulation for FI had a median cure rate of 38.6% (IQR, 35.6-40.6%).

CONCLUSIONS

Many individuals were not cured and hence may continue to rely on containment. No studies were found assessing success of containment strategies. There was a lack of data in the disabled and in those with neurological diseases, in the elderly and those with cognitive impairment. Surgical interventions were effective for stress UI. Other interventions for UI and FI showed lower cure rates. Many individuals are likely to be reliant on containment strategies.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42015023763 .

Washout policies in long-term indwelling urinary catheterisation in adults

BACKGROUND

People requiring long-term bladder draining with an indwelling catheter can experience catheter blockage. Regimens involving different solutions can be used to wash out catheters with the aim of preventing blockage. This is an update of a review published in 2010.

OBJECTIVES

To determine if certain washout regimens are better than others in terms of effectiveness, acceptability, complications, quality of life and critically appraise and summarise economic evidence for the management of long-term indwelling urinary catheterisation in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings to 23 May 2016. We also examined all reference lists of identified trials and contacted manufacturers and researchers in the field.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing catheter washout policies (e.g. washout versus no washout, different washout solutions, frequency, duration, volume, concentration, method of administration) in adults (aged 16 years and above) in any setting (i.e. hospital, nursing/residential home, community) with an indwelling urethral or suprapubic catheter for more than 28 days.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. Disagreements were resolved by discussion. Data were assessed and analysed as described in the Cochrane Handbook. If data in trials were not fully reported, clarification was sought from the study authors. For categorical outcomes, the numbers reporting an outcome were related to the numbers at risk in each group to derive a risk ratio (RR). For continuous outcomes, means and standard deviations were used to derive mean differences (MD).

MAIN RESULTS

We included seven trials involving a total of 349 participants, 217 of whom completed the studies. Three were cross-over and four were parallel-group randomised controlled trials (RCTs). Of these, two trials were added for this update (one parallel-group RCT with 40 participants and one cross-over RCT with 67 participants). Analyses of three cross-over trials yielded suboptimal results because they were based on between-group differences rather than individual participants' differences for sequential interventions. Two parallel-group trials had limited clinical value: one combined results for suprapubic and urethral catheters and the other provided data for only four participants. Only one trial was free of significant methodological limitations, but there were difficulties with recruitment and maintaining participants in this study.The included studies reported data on six of the nine primary and secondary outcome measures. None of the trials addressed: number of catheters used, washout acceptability measures (including patient satisfaction, patient discomfort, pain and ease of use), or health status/measures of psychological health; very limited data were collected for health economic outcomes. Trials assessed only three of the eight intervention comparisons identified. Two trials reported in more than one comparison group.Four trials compared washout (either saline or acidic solution) with no washout. We are uncertain if washout solutions (saline or acidic), compared to no washout solutions, has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.Four trials compared different types of washout solution; saline versus acidic solutions (2 trials); saline versus acidic solution versus antibiotic solution (1 trial); saline versus antimicrobial solution (1 trial). We are uncertain if type of washout solution has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.One trial compared different compositions of acidic solution (stronger versus weaker solution). We are uncertain if different compositions of acidic solutions has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because only 14 participants (of 25 who were recruited) completed this 12 week, three arm trial.Four studies reported on possible harmful effects of washout use, such as blood in the washout solution, changes in blood pressure and bladder spasms.There were very few small trials that met the review inclusion criteria. The high risk of bias of the included studies resulted in the evidence being graded as low or very low quality.

AUTHORS' CONCLUSIONS

Data from seven trials that compared different washout policies were limited, and generally, of poor methodological quality or were poorly reported. The evidence was not adequate to conclude if washouts were beneficial or harmful. Further rigorous, high quality trials that are adequately powered to detect benefits from washout being performed as opposed to no washout are needed. Trials comparing different washout solutions, washout volumes, and frequencies or timings are also needed.

Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT)

BACKGROUND

The use of transvaginal mesh and biological graft material in prolapse surgery is controversial and has led to a number of enquiries into their safety and efficacy. Existing trials of these augmentations are individually too small to be conclusive. We aimed to compare the outcomes of prolapse repair involving either synthetic mesh inlays or biological grafts against standard repair in women.

METHODS

We did two pragmatic, parallel-group, multicentre, randomised controlled trials for our study (PROSPECT [PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trials]) in 35 centres (a mix of secondary and tertiary referral hospitals) in the UK. We recruited women undergoing primary transvaginal anterior or posterior compartment prolapse surgery by 65 gynaecological surgeons in these centres. We randomly assigned participants by a remote web-based randomisation system to one of the two trials: comparing standard (native tissue) repair alone with standard repair augmented with either synthetic mesh (the mesh trial) or biological graft (the graft trial). We assigned women (1:1:1 or 1:1) within three strata: assigned to one of the three treatment options, comparison of standard repair with mesh, and comparison of standard repair with graft. Participants, ward staff, and outcome assessors were masked to randomisation where possible; masking was obviously not possible for the surgeon. Follow-up was for 2 years after the surgery; the primary outcomes, measured at 1 year and 2 years, were participant-reported prolapse symptoms (i.e. the Pelvic Organ Prolapse Symptom Score [POP-SS]) and condition-specific (ie, prolapse-related) quality-of-life scores, analysed in the modified intention-to-treat population. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN60695184.

FINDINGS

Between Jan 8, 2010, and Aug 30, 2013, we randomly allocated 1352 women to treatment, of whom 1348 were included in the analysis. 865 women were included in the mesh trial (430 to standard repair alone, 435 to mesh augmentation) and 735 were included in the graft trial (367 to standard repair alone, 368 to graft augmentation). Because the analyses were carried out separately for each trial (mesh trial and graft trial) some women in the standard repair arm assigned to all treatment options were included in the standard repair group of both trials. 23 of these women did not receive any surgery (15 in the mesh trial, 13 in the graft trial; five were included in both trials) and were included in the baseline analyses only. Mean POP-SS at 1 year did not differ substantially between comparisons (standard 5·4 [SD 5·5] vs mesh 5·5 [5·1], mean difference 0·00, 95% CI -0·70 to 0·71; p=0·99; standard 5·5 [SD 5·6] vs graft 5·6 [5·6]; mean difference -0·15, -0·93 to 0·63; p=0·71). Mean prolapse-related quality-of-life scores also did not differ between groups at 1 year (standard 2·0 [SD 2·7] vs mesh 2·2 [2·7], mean difference 0·13, 95% CI -0·25 to 0·51; p=0·50; standard 2·2 [SD 2·8] vs graft 2·4 [2·9]; mean difference 0·13, -0·30 to 0·56; p=0·54). Mean POP-SS at 2 years were: standard 4·9 (SD 5·1) versus mesh 5·3 (5·1), mean difference 0·32, 95% CI -0·39 to 1·03; p=0·37; standard 4·9 (SD 5·1) versus graft 5·5 (5·7); mean difference 0·32, -0·48 to 1·12; p=0·43. Prolapse-related quality-of-life scores at 2 years were: standard 1·9 (SD 2·5) versus mesh 2·2 (2·6), mean difference 0·15, 95% CI -0·23 to 0·54; p=0·44; standard 2·0 (2·5) versus graft 2·2 (2·8); mean difference 0·10, -0·33 to 0·52; p=0·66. Serious adverse events such as infection, urinary retention, or dyspareunia or other pain, excluding mesh complications, occurred with similar frequency in the groups over 1 year (mesh trial: 31/430 [7%] with standard repair vs 34/435 [8%] with mesh, risk ratio [RR] 1·08, 95% CI 0·68 to 1·72; p=0·73; graft trial: 23/367 [6%] with standard repair vs 36/368 [10%] with graft, RR 1·57, 0·95 to 2·59; p=0·08). The cumulative number of women with a mesh complication over 2 years in women actually exposed to synthetic mesh was 51 (12%) of 434.

INTERPRETATION

Augmentation of a vaginal repair with mesh or graft material did not improve women's outcomes in terms of effectiveness, quality of life, adverse effects, or any other outcome in the short term, but more than one in ten women had a mesh complication. Therefore, follow-up is vital to identify any longer-term potential benefits and serious adverse effects of mesh or graft reinforcement in vaginal prolapse surgery.

FUNDING

UK National Institute of Health Research.

Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial

BACKGROUND

Pelvic floor muscle training can reduce prolapse severity and symptoms in women seeking treatment. We aimed to assess whether this intervention could also be effective in secondary prevention of prolapse and the need for future treatment.

METHODS

We did this multicentre, parallel-group, randomised controlled trial at three centres in New Zealand and the UK. Women from a longitudinal study of pelvic floor function after childbirth were potentially eligible for inclusion. Women of any age who had stage 1-3 prolapse, but had not sought treatment, were randomly assigned (1:1), via remote computer allocation, to receive either one-to-one pelvic floor muscle training (five physiotherapy appointments over 16 weeks, and annual review) plus Pilates-based pelvic floor muscle training classes and a DVD for home use (intervention group), or a prolapse lifestyle advice leaflet (control group). Randomisation was minimised by centre, parity (three or less vs more than three deliveries), prolapse stage (above the hymen vs at or beyond the hymen), and delivery method (any vaginal vs all caesarean sections). Women and intervention physiotherapists could not be masked to group allocation, but allocation was masked from data entry researchers and from the trial statistician until after database lock. The primary outcome was self-reported prolapse symptoms (Pelvic Organ Prolapse Symptom Score [POP-SS]) at 2 years. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01171846.

FINDINGS

Between Dec 21, 2008, and Feb 24, 2010, in New Zealand, and Oct 27, 2010, and Sept 5, 2011, in the UK, we randomly assigned 414 women to the intervention group (n=207) or the control group (n=207). One participant in each group was excluded after randomisation, leaving 412 women for analysis. At baseline, 399 (97%) women had prolapse above or at the level of the hymen. The mean POP-SS score at 2 years was 3·2 (SD 3·4) in the intervention group versus 4·2 (SD 4·4) in the control group (adjusted mean difference -1·01, 95% CI -1·70 to -0·33; p=0·004). The mean symptom score stayed similar across time points in the control group, but decreased in the intervention group. Three adverse events were reported, all of which were in the intervention group (one women had a fall, one woman had a pain in her tail bone, and one woman had chest pain and shortness of breath).

INTERPRETATION

Our study shows that pelvic floor muscle training leads to a small, but probably important, reduction in prolapse symptoms. This finding will be important for women and caregivers considering preventive strategies.

FUNDING

Wellbeing of Women charity, the New Zealand Continence Association, and the Dean's Bequest Fund of Dunedin School of Medicine.

Is there a relationship between ultrasound scanning ability (sonography) and visuospatial perception or psychomotor ability?

BACKGROUND

Competent sonography is thought to include a unique combination of skills not yet fully defined. This presents challenges when recruiting the correct people for training. Skills are thought to include visuospatial perception and psychomotor skills, but little is known about the relationship between these aptitudes and scanning ability. This feasibility study explored such relationships, to identify evaluation techniques which may improve selection and recruitment.

METHODS

A sample of 30 experienced ultrasound practitioners and 30 trainees at commencement and on completion of training were administered eight tests.

RESULTS

No significant relationships between experienced practitioners' or trainees' visuospatial abilities or psychomotor abilities and scanning abilities were found. Results demonstrated that two of the visuospatial perception tests were not influenced by training and therefore, may be measuring the innate skills of ultrasound practitioners. As ultrasound practitioners had not performed any of the tests previously, ranges of scores for each of the eight tests were established for this group. This included measures for psychomotor skills which added to the current body of knowledge for sonography.

CONCLUSIONS

Although no significant correlations were found between participants' visuospatial perception or psychomotor abilities and scanning ability, performance on the Obstetric Structured Assessment Test (combining all the skills required) pre-training gave the best indication of post-training scanning performance. The Obstetric Structured Assessment Test may prove a useful tool for initial assessment of potential trainees but abilities will require further investigation.

Two parallel, pragmatic, UK multicentre, randomised controlled trials comparing surgical options for upper compartment (vault or uterine) pelvic organ prolapse (the VUE Study): study protocol for a randomised controlled trial

BACKGROUND

One in three women who have a prolapse operation will go on to have another operation, though not necessarily in the same compartment. Surgery can result in greater impairment of quality of life than the original prolapse itself (such as the development of new-onset urinary incontinence, or prolapse at a different site). Anterior and posterior prolapse surgery is most common (90 % of operations), but around 43 % of women also have a uterine (34 %) or vault (9 %) procedure at the same time. There is not enough evidence from randomised controlled trials (RCTs) to guide management of vault or uterine prolapse. The Vault or Uterine prolapse surgery Evaluation (VUE) study aims to assess the surgical management of upper compartment pelvic organ prolapse (POP) in terms of clinical effectiveness, cost-effectiveness and adverse events.

METHODS/DESIGN

VUE is two parallel, pragmatic, UK multicentre, RCTs (Uterine Trial and Vault Trial). Eligible for inclusion are women with vault or uterine prolapse: requiring a surgical procedure, suitable for randomisation and willing to be randomised. Randomisation will be computer-allocated separately for each trial, minimised on: requiring concomitant anterior and/or posterior POP surgery or not, concomitant incontinence surgery or not, age (under 60 years or 60 years and older) and surgeon. Participants will be randomly assigned, with equal probability to intervention or control arms in either the Uterine Trial or the Vault Trial. Uterine Trial participants will receive either a vaginal hysterectomy or a uterine preservation procedure. Vault Trial participants will receive either a vaginal sacrospinous fixation or an abdominal sacrocolpopexy. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomisation) and also reviewed in clinic 12 months post surgery. The primary outcome is the participant-reported Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months post randomisation.

DISCUSSION

Demonstrating the efficacy of vault and uterine prolapse surgeries is relevant not only to patients and clinicians but also to health care providers, both in the UK and globally.

TRIAL REGISTRATION

Current controlled trials ISRCTN86784244 (assigned 19 October 2012), and the first subject was randomly assigned on 1 May 2013.

A theory-informed approach to developing visually mediated interventions to change behaviour using an asthma and physical activity intervention exemplar

BACKGROUND

Visualisation techniques are used in a range of healthcare interventions. However, these frequently lack a coherent rationale or clear theoretical basis. This lack of definition and explicit targeting of the underlying mechanisms may impede the success of and evaluation of the intervention. We describe the theoretical development, deployment, and pilot evaluation, of a complex visually mediated behavioural intervention. The exemplar intervention focused on increasing physical activity among young people with asthma. We employed an explicit five-stage development model, which was actively supported by a consultative user group. The developmental stages involved establishing the theoretical basis, establishing a narrative structure, visual rendering, checking interpretation, and pilot testing. We conducted in-depth interviews and focus groups during early development and checking, followed by an online experiment for pilot testing. A total of 91 individuals, including young people with asthma, parents, teachers, and health professionals, were involved in development and testing.

RESULTS

Our final intervention consisted of two components: (1) an interactive 3D computer animation to create intentions and (2) an action plan and volitional help sheet to promote the translation of intentions to behaviour. Theory was mediated throughout by visual and audio forms. The intervention was regarded as highly acceptable, engaging, and meaningful by all stakeholders. The perceived impact on asthma understanding and intentions was reported positively, with most individuals saying that the 3D computer animation had either clarified a range of issues or made them more real. Our five-stage model underpinned by extensive consultation worked well and is presented as a framework to support explicit decision-making for others developing theory informed visually mediated interventions.

CONCLUSIONS

We have demonstrated the ability to develop theory-based visually mediated behavioural interventions. However, attention needs to be paid to the potential ambiguity associated with images and thus the concept of visual literacy among patients. Our revised model may be helpful as a guide to aid development, acceptability, and ultimately effectiveness.

Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used

BACKGROUND

Many complex intervention trials fail to show an intervention effect. Although this may be due to genuine ineffectiveness, it may also be the result of sub-optimal intervention design, implementation failure or a combination of these. Given current financial constraints and the pressure to reduce waste and increase value in health services research, pre-trial strategies are needed to reduce the likelihood of design or implementation failure and to maximise the intervention's potential for effectiveness. In this scoping review, we aimed to identify and synthesise the available evidence relating to the strategies and methods used to 'optimise' complex interventions at the pre-trial stage.

METHODS

We searched MEDLINE, CINAHL, AMED, PsycINFO and ProQuest Nursing & Allied Health Source for papers published between January 2000 and March 2015. We included intervention development and optimisation studies that explored potential intervention weaknesses and limitations before moving to a definitive randomised controlled trial (RCT). Two reviewers independently applied selection criteria and systematically extracted information relating to the following: study characteristics; intervention under development; framework used to guide the development process; areas of focus of the optimisation process, methods used and outcomes of the optimisation process. Data were tabulated and summarised in a narrative format.

RESULTS

We screened 3968 titles and 231 abstracts for eligibility. Eighty-nine full-text papers were retrieved; 27 studies met our selection criteria. Optimisation strategies were used for a range of reasons: to explore the feasibility and acceptability of the intervention to patients and healthcare professionals; to estimate the effectiveness and cost-effectiveness of different combinations of intervention components; and to identify potential barriers to implementation. Methods varied widely across studies, from interviews and focus groups to economic modelling and probability analysis.

CONCLUSIONS

The review identifies a range of optimisation strategies currently used. Although a preliminary classification of these strategies can be proposed, a series of questions remain as to which methods to use for different interventions and how to determine when the intervention is ready or 'optimised enough' to be tested in a RCT. Future research should explore potential answers to the questions raised, to guide researchers in the development and evaluation of more effective interventions.

Intravitreal anti-vascular endothelial growth factor combined with half-fluence photodynamic therapy for choroidal neovascularization in chronic central serous chorioretinopathy

PurposeTo evaluate the results of indocyanine green angiography (ICGA)-guided verteporfin photodynamic therapy (PDT) with half-fluence rate combined with intravitreal application of anti-VEGF in treating choroidal neovascularization (CNV) in chronic central serous chorioretinopathy (CSCR).Patients and methodsIn this retrospective cohort study 17 consecutive patients with secondary CNV due to chronic CSCR had their diagnosis verified with fluorescein angiography (FA) and ICGA at baseline. All eyes received either intravitreal ranibizumab (IVR) or bevacizumab (IVB). On the consecutive day following the initial IVR/IVB treatment, ICGA-guided verteporfin (6 mg/m(2)) PDT with half-fluence rate (25 J/cm(2)) was performed on every patient. IVR or IVB was rescheduled on a pro re nata regimen. Main outcome measures were changes in visual acuity (VA) according to the ETDRS letter score and changes in the central foveal thickness (CFT).ResultsBest-corrected VA at baseline was 65.6 letters (±6.7; n=17) according to the ETDRS letter score. At 12 months, mean ETDRS letter score improved to 71.2 letters (P=0.34). CFT was 309 μm and decreased to 216 μm at month 12 control (P=0.0004). Nine eyes (52.9%) received additional treatment with IVR/IVB due to recurrence of subretinal fluid, with an overall mean number of IVR/IVB treatment of 1.8±3.6 per patient with no systemic side effects during 12 months' follow-up.ConclusionsIVR or IVB combined with ICGA-guided half-fluence PDT with verteporfin is effective in treating CNV in chronic CSCR, with choroidal hyperpermeability in ICGA, resulting in stable vision and significant reduction of CFT.

Abdominal massage for the alleviation of symptoms of constipation in people with Parkinson's: a randomised controlled pilot study

BACKGROUND

constipation is one of the most common non-motor features of Parkinson's affecting up to 90% of patients. In severe cases, it can lead to hospitalisation and is usually managed with laxatives which in themselves can lead to side effects. Abdominal massage has been used as adjunct in the management of constipation in various populations, but not in those with Parkinson's.

OBJECTIVE

the primary objective was to test the recruitment, retention and the appropriateness of the intervention methods and outcome measures.

METHODS

thirty-two patients with Parkinson's were recruited from three movement disorder clinics and were randomised to receive either 6 weeks of daily abdominal massage plus lifestyle advice on managing constipation (Intervention Group, n = 16) or lifestyle advice (Control Group, n = 16). Data were collected prior to group allocation (Baseline), at Week 6 (following intervention) and 4 weeks later (Week 10). Outcome tools included the Gastrointestinal Rating Scale and a bowel diary.

RESULTS

constipation has a negative impact on quality of life. The study recruited to target, retention was high and adherence to the study processes was good. The massage was undertaken as recommended during the 6 weeks of intervention with 50% continuing with the massage at 10 weeks. Participants in both groups demonstrated an improvement in symptoms, although this was not significantly different between the groups.

CONCLUSION

abdominal massage, as an adjunct to management of constipation, offers an acceptable and potentially beneficial intervention to patients with Parkinson's.

A survey of prolapse practice in UK women's health physiotherapists: what has changed in the last decade?

Introduction and hypothesis

Prolapse is a common female problem, and conservative treatments such as pelvic floor muscle training (PFMT) are important options for women. Evidence supporting the effectiveness of PFMT for prolapse has grown over the last decade, and it was hypothesised that practice and practice guidelines would have developed in line with the evidence. To assess this, up-to-date information about the practice of physiotherapists working in women’s health regarding their treatment of prolapse was required.

Methods

An online survey sent to members of the Association of Chartered Physiotherapists in Women’s Health and the Chartered Physiotherapists Promoting Continence. Results were compared with those of an earlier survey undertaken in 2002.

Results

A 49 % response rate was achieved. The majority of respondents were senior physiotherapists (55 %) and had worked in women’s health for more than 10 years. Respondents were treating significantly more women with prolapse than a decade before: 36 % vs 14 % treated more than 50 women per year in 2002 and 2013 respectively (p < 0.001). Individualised PFMT (93 %), lifestyle advice (92 %) and biofeedback-assisted PFMT (83 %) were the most common treatment elements, with four being the average number of appointments. Forty-eight percent had changed their practice as a result of recent research; however, scepticism amongst medics, the referral of women directly for surgery, and constraints on resources were thought to be barriers to wider implementation of the evidence of PFMT for prolapse.

Conclusions

There has been uptake of evidence-based prolapse practice by UK specialist physiotherapists in the last decade. Further research targeting the implementation of this evidence would be valuable in addressing potential barriers, and in supporting the need for physiotherapy in the treatment of prolapse.

A first-in-human phase I and pharmacokinetic study of CP-4126 (CO-101), a nucleoside analogue, in patients with advanced solid tumours

BACKGROUND

CP-4126 (gemcitabine elaidate, previously CO-101) is a lipid-drug conjugate of gemcitabine designed to circumvent human equilibrative nucleoside transporter1-related resistance to gemcitabine. The purpose of this study was to determine the maximum tolerated dose (MTD) and the recommended phase II dose (RP2D) of CP-4126, and to describe its pharmacokinetic profile.

METHODS

Eligible patients with advanced refractory solid tumours, and adequate performance status, haematological, renal and hepatic function, were treated with one of escalating doses of CP-4126 administered by a 30-min intravenous infusion on days 1, 8 and 15 of a 28-day cycle. Blood and urine samples were collected to determine the pharmacokinetics (PKs) of CP-4126.

RESULTS

Forty-three patients, median age 59 years (range 18-76; male = 27, female = 16), received one of ten dose levels (30-1600 mg/m(2)). Dose-limiting toxicities included grade 3 anaemia, grade 3 fatigue and grade 3 elevation of transaminases. The MTD and RP2D were 1250 mg/m(2) on basis of the toxicity and PK data. CP-4126 followed dose-dependent kinetics and maximum plasma concentrations occurred at the end of CP-4126 infusion. Seven patients achieved stable disease sustained for ≥3 months, including two patients with pancreatic cancer who had progressed on or after gemcitabine exposure.

CONCLUSIONS

CP-4126 was well tolerated with comparable toxicity profile to gemcitabine. Future studies are required to determine its anti-tumour efficacy, either alone or in combination with other cytotoxic chemotherapy regimens.

Caring for continence in stroke care settings: a qualitative study of patients' and staff perspectives on the implementation of a new continence care intervention

OBJECTIVES

Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke.

DESIGN

Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis.

SETTING

Mixed acute and rehabilitation stroke ward.

PARTICIPANTS

Stroke patients and nursing staff that experienced an enhanced continence care intervention.

RESULTS

Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence.

CONCLUSION

Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 State-of-the-Science Seminar

AIMS

To summarize the findings and "expert-panel" consensus of the State-of-the-Science Seminar on pelvic floor muscle training (PFMT) adherence held prior to the 41st International Continence Society scientific meeting, Glasgow, 2011.

METHODS

Summaries of research and theory about PFMT adherence (based on a comprehensive literature search) were presented by subject experts at the 2011 Seminar to generate discussion and guidance for clinical practice and future research. Supplemental research, post-seminar, resulted in, three review papers summarizing: (1) relevant behavioral theories, (2) adherence measurement, determinants and effectiveness of PFMT adherence interventions, and (3) patients' PFMT experiences. A fourth, reported findings from an online survey of health professionals and the public.

RESULTS

Few high-quality studies were found. Paper I summarizes 12 behavioral frameworks relevant to theoretical development of PFMT adherence interventions and strategies. Findings in Paper II suggest both PFMT self-efficacy and intention-to-adhere predict PFMT adherence. Paper III identified six potential adherence modifiers worthy of further investigation. Paper IV found patient-related factors were the biggest adherence barrier to PFMT adherence.

CONCLUSION

Given the lack of high-quality studies, the conclusions were informed by expert opinion. Adherence is central to short- and longer-term PFMT effect. More attention and explicit reporting is needed regarding: (1) applying health behavior theory in PFMT program planning; (2) identifying adherence determinants; (3) developing and implementing interventions targeting known adherence determinants; (4) using patient-centred approaches to evaluating adherence barriers and facilitators; (5) measuring adherence, including refining and testing instruments; and (6) testing the association between adherence and PFMT outcome.

Pelvic-Floor-Muscle Training Adherence: Tools, Measurements and Strategies-2011 ICS State-of-the-Science Seminar Research Paper II of IV

AIMS

This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the International Continence Society's 2011 State-of-the-Science Conference, aims to (1) identify and collate current adherence outcome measures, (2) report the determinants of adherence, (3) report on PFMT adherence strategies, and (4) make actionable clinical and research recommendations.

METHOD

Data were amassed from a literature review and an expert panel (2011 conference), following consensus statement methodology. Experts in pelvic floor dysfunction collated and synthesized the evidence and expert opinions on PFMT adherence for urinary incontinence (UI) and lower bowel dysfunction in men and women and pelvic organ prolapse in women.

RESULTS

The literature was scarce for most of the studied populations except for limited research on women with UI.

OUTCOME MEASURES

Exercise diaries were the most widely-used adherence outcome measure, PFMT adherence was inconsistently monitored and inadequately reported. Determinants: Research, mostly secondary analyses of RCTs, suggested that intention to adhere, self-efficacy expectations, attitudes towards the exercises, perceived benefits and a high social pressure to engage in PFMT impacted adherence.

STRATEGIES

Few trials studied and compared adherence strategies. A structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence.

CONCLUSION

The literature on adherence outcome measures, determinants and strategies remains scarce for the studied populations with PFM dysfunction, except in women with UI. Although some current adherence findings can be applied to clinical practice, more effective and standardized research is urgently needed across all the sub-populations.

Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study

OBJECTIVE

To investigate the extent of persistent urinary incontinence (UI) 12 years after birth, and association with delivery-mode history and other factors.

DESIGN

Twelve-year longitudinal cohort study.

SETTING

Maternity units in Aberdeen, Birmingham, and Dunedin.

POPULATION

Women who returned questionnaires 3 months and 12 years after index birth.

METHODS

Data on all births over a period of 12 months were obtained from the units and then women were contacted by post.

MAIN OUTCOME MEASURE

Persistent UI reported at 12 years, with one or more previous contact.

RESULTS

Of 7879 women recruited at 3 months, 3763 (48%) responded at 12 years, with 2944 also having responded at 6 years; non-responders had similar obstetric characteristics. The prevalence of persistent UI was 37.9% (1429/3763). Among those who had reported UI at 3 months, 76.4% reported it at 12 years. Women with persistent UI had lower SF12 quality of life scores. Compared with having only spontaneous vaginal deliveries (SVDs), women who delivered exclusively by caesarean section were less likely to have persistent UI (odds ratio, OR 0.42, 95% CI 0.33-0.54). This was not the case in women who had a combination of caesarean section and SVD births (OR 1.01, 95% CI 0.78-1.30). Older age at first birth, greater parity, and overweight/obesity were associated with persistent UI. Of 54 index primiparae with UI before pregnancy, 46 (85.2%) had persistent UI.

CONCLUSIONS

This study, demonstrating that UI persists to 12 years in about three-quarters of women, and that risk was only reduced with caesarean section if women had no other delivery mode, has practice implications.

TWEETABLE ABSTRACT

A longitudinal study of 3763 women showed a prevalence of persistent UI 12 years after birth of 37.9%.

High-resolution crystal structure and IgE recognition of the major grass pollen allergen Phl p 3

BACKGROUND

Group 2 and 3 grass pollen allergens are major allergens with high allergenic activity and exhibit structural similarity with the C-terminal portion of major group 1 allergens. In this study, we aimed to determine the crystal structure of timothy grass pollen allergen, Phl p 3, and to study its IgE recognition and cross-reactivity with group 2 and group 1 allergens.

METHODS

The three-dimensional structure of Phl p 3 was solved by X-ray crystallography and compared with the structures of group 1 and 2 grass pollen allergens. Cross-reactivity was studied using a human monoclonal antibody which inhibits allergic patients' IgE binding and by IgE inhibition experiments with patients' sera. Conformational Phl p 3 IgE epitopes were predicted with the algorithm SPADE, and Phl p 3 variants containing single point mutations in the predicted IgE binding sites were produced to analyze allergic patients' IgE binding.

RESULTS

Phl p 3 is a globular β-sandwich protein showing structural similarity to Phl p 2 and the Phl p 1-C-terminal domain. Phl p 3 showed IgE cross-reactivity with group 2 allergens but not with group 1 allergens. SPADE identified two conformational IgE epitope-containing areas, of which one overlaps with the epitope defined by the monoclonal antibody. The mutation of arginine 68 to alanine completely abolished binding of the blocking antibody. This mutation and a mutation of D13 in the predicted second IgE epitope area also reduced allergic patients' IgE binding.

CONCLUSION

Group 3 and group 2 grass pollen allergens are cross-reactive allergens containing conformational IgE epitopes. They lack relevant IgE cross-reactivity with group 1 allergens and therefore need to be included in diagnostic tests and allergen-specific treatments in addition to group 1 allergens.