Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.

Prevention and treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and around 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for prevention and treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 December 2004 and 26 October 2004, respectively), CINAHL (January 1982 to November 2004), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Seven trials with a total of 399 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. No two trials addressed the same comparison. Four trials tested an intervention against usual care, including acupuncture, timed voiding, and two types of specialist professional intervention. One cross-over trial tested an intervention (oestrogen) against placebo. One trial tested a specific intervention (oxybutynin) against another intervention (timed voiding), and one trial tested a combined intervention (sensory-motor biofeedback plus timed voiding) against a single component intervention (timed voiding alone). Reported data were insufficient to evaluate acupuncture or timed voiding versus usual care, oxybutynin versus timed voiding, or sensory motor biofeedback plus timed voiding versus usual care. Evidence from a single small trial suggested that structured assessment and management of care in early rehabilitation may reduce the number of people with incontinence at hospital discharge (1/21 versus 10/13; RR 0.06, 95% CI 0.01 to 0.43), and have other benefits. Evidence from another trial suggested that assessment and management of care by Continence Nurse Practitioners in a community setting may reduce the number of urinary symptoms (48/89 versus 38/54; RR 0.77, 95% CI 0.59 to 0.99), and increase satisfaction with care.

AUTHORS' CONCLUSIONS

There was suggestive evidence that specialist professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence after stroke. Data from trials of other physical, behavioural, complementary and anticholinergic drug interventions are insufficient to guide continence care of adults after stroke.

Tolerance to the behavioural effects of the selective 5-HT(1A) agent, ipsapirone

Effects of ipsaprione on rats were studied in procedures in which tolerance was assessed with operant responding and in feeding tests. Initially, the suppressant effect of ipsapirone on Fixed Ratio 20 behaviour was studied. During 33 days treatment (7.5mg/kg daily) no tolerance developed. Subsequently, the same rats received ipsapirone (7.5mg/kg) three times daily, at intervals of 2.5h, the first injection preceding operant sessions. Over 10 further days of treatment, there was still no evidence of tolerance. In a second study, ipsapirone was again administered at 7.5mg/kg before operant sessions, followed by 2 daily injections of 20mg/kg, at at 2.5h intervals after operant sessions. Under these conditions, some tolerance developed although it was incomplete and rapidly lost. The effects of ipsapirone on operant responding were found to be short-lasting. The suppressant action of 7.5mg/kg of ipsapirone (to 50% of baseline) was abolished if the drug was injected 4h before sessions. In other studies, we confirmed that tolerance develops very rapidly to hyperphagic actions of ipsapirone (see Kennett et al., 1987). We conclude that: 1) tolerance develops at differing rates to various effects of ipsapirone; 2) only those effects of ipsapirone (and related agents) which involve activation of presynaptic autoreceptors show rapid tolerance; 3) tolerance develops to effects on operant responding only if high doses are administered frequently. Since ipsapirone is short-acting, tolerance to such effects develops only when drug is continuously present in body tissue. The tolerance observed (to effects on operant behaviour) was probably of a pharmacodynamic nature and did not involve learning processes.

The COSTAR wheelchair study: a two-centre pilot study of self-propulsion in a wheelchair in early stroke rehabilitation. Collaborative Stroke Audit and Research

OBJECTIVE

It is uncertain whether self-propulsion in a wheelchair should be encouraged or discouraged in the early stages of stroke rehabilitation.

DESIGN

A two-centre pilot study to assess the feasibility of performing a multicentre randomized controlled trial on this subject.

SETTING

Clatterbridge and Aintree Stroke Rehabilitation Units, Merseyside, UK.

SUBJECTS

Forty early stroke patients (mean age 67 years) in whom it was uncertain whether self-propulsion in a wheelchair should be encouraged were studied.

INTERVENTION

A central randomization service at Newcastle University was used to determine the policy about wheelchair provision and use for each patient. They were allocated to either an 'encouraged to self-propel' or a 'discouraged from self-propulsion group'. OUTCOME MEASURES USED: Independent outcome assessment was performed by postal questionnaire and telephone interview using the Barthel ADL Scale, Nottingham Extended ADL Scales and the shortened General Health Questionnaire (GHQ-12) at 3 and 12 months. Patient's length of stay and their Ashworth tone score were also measured either at three months or when they were discharged from hospital.

RESULTS

After considerable preparation time it was possible to conduct a trial on self-propulsion in early stroke rehabilitation in the two-pilot centres. No major differences were found between the pilot groups for any of the outcome measures.

CONCLUSIONS

A multicentre randomized controlled trial to assess this question is feasible but further work is being conducted before proceeding, to satisfy the concerns expressed to our group regarding the appropriateness of the intervention and the outcome measures.

Time-weighted nursing demand is a better predictor than midnight census of nursing supply in an intensive care unit

PURPOSE

Labor costs are the largest fraction of operating costs in an intensive care unit (ICU). Estimation of appropriate nursing supply is frequently based on the midnight census of patients, which is a "snapshot" view of the ICU. We postulated that the midnight census would not correlate as well as time-weighted nursing demand (a calculation of need for nursing staff) with the actual number of nurses who were required to staff the ICU (nursing supply). The purpose of this study was to compare the correlation between midnight census and actual nursing supply with the correlation between time-weighted nursing demand and nursing supply.

MATERIALS AND METHODS

We measured nursing activity, midnight census, and actual nursing supply for each of 77 consecutive days in a 14-bed medical-surgical ICU within a 450-bed tertiary care teaching hospital. We calculated time-weighted nursing demand based on 1:1 nursing for ICU patients, 1:2 nursing for step-down patients, 0.5 additional nurse hours for each cardiac arrest, and 0.5 additional nurse hours for each new admission to the ICU.

RESULTS

There was a correlation between midnight census and nursing supply (r2 = .42, P<.0001) and between nursing demand and nursing supply (r2 = .83, P<.0001). The correlation coefficient for the relationship between nursing demand and nursing supply was significantly greater than that for the relationship between midnight census and nursing supply (P<.01).

CONCLUSIONS

Time-weighted nursing demand is a better predictor than midnight census of nursing supply in an ICU.

Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity

OBJECTIVES

To establish reliability of the Tone Assessment Scale and modified Ashworth scale in acute stroke patients.

SETTING

A North Liverpool university hospital.

PATIENTS

Eighteen men and 14 women admitted with acute stroke and still in hospital at the study start date (median age, 74 yrs; median Barthel score, 8).

MAIN OUTCOME MEASURES

The modified Ashworth scale and the Tone Assessment Scale.

STUDY DESIGN

The 32 patients were examined with both scales on the same occasion by two raters (interrater comparison) and on two occasions by one rater (intrarater comparison).

RESULTS

The reliability of the modified Ashworth scale was very good (kappa = .84 for interrater and .83 for intrarater comparisons). The reliability of the Tone Assessment Scale was not as strong as the modified Ashworth scale, with marked variability in the assessment of posture (kappa = .22 to .50 for interrater and .29 to .55 for intrarater comparisons) and associated reaction (kappa/kappaW = -.05 to .79 for interrater and .19 to .83 for intrarater comparisons). However, those aspects of the Tone Assessment Scale that addressed response to passive movement and that are scored similarly to the modified Ashworth scale showed good to very good interrater reliability (kappaW = .79 to .92) and good to very good intrarater reliability (kappaW = .72 to .86), except for the question related to movement at the ankle where agreement was only moderate (kappaW = .59).

CONCLUSIONS

The modified Ashworth scale is reliable. The section of the Tone Assessment Scale relating to response to passive movement is reliable at various joints, except the ankle. It may assist in studies on the prevalence of spasticity after stroke and the relationship between tone and function. Further development of a measure of spasticity at the ankle is required. The Tone Assessment Scale is not reliable for measuring posture and associated reactions.

Practice guideline for arterial blood gas measurement in the intensive care unit decreases numbers and increases appropriateness of tests

OBJECTIVE

To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests (according to criteria in the guideline) for up to 1 yr after introduction of the guideline.

DESIGN

Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods: two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months, 6 to 7 months, and 12 to 13 months after introduction of the guideline.

SETTING

A ten-bed multidisciplinary intensive care unit (ICU) within a 500-bed tertiary teaching hospital.

PATIENTS

A random sample of 30 patients admitted to the ICU during each of the periods specified above.

INTERVENTIONS

The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline.

MEASUREMENTS AND MAIN RESULTS

At 2 to 3 months, test numbers decreased from 4.9 +/- 1.6 to 3.1 +/- 1.8 (SD) tests/patient/day and to 2.4 +/- 1.2 tests/patient/day at 12 to 13 months. Appropriateness increased from a mean of 44% at baseline to 78% at 2 to 3 months and 79% at 12 to 13 months. There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation. Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $19.18 per patient per day.

CONCLUSIONS

Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome.

In vivo interactions of NAN-190, a putative selective 5-HT1A antagonist, with ipsapirone

The actions of NAN-190, a putative 5-HT1A antagonist, were assessed in rats. The selective 5-HT1A agent ipsapirone suppressed operant responding, but this effect was not antagonised by NAN-190, which suppressed responding itself in a dose-related manner, and had additive effects when administered with ipsapirone. These data do not support suggestions that NAN-190 is a 5-HT1A antagonist. NAN-190 may be a 5-HT1A partial agonist which can antagonise effects of full 5-HT1A agonists.

Paroxetine, a selective 5-hydroxytryptamine uptake inhibitor with antidepressant properties, lacks amphetamine-like stimulus properties in an operant drug discrimination bioassay in rodents

To evaluate whether the novel antidepressant paroxetine has any possible amphetamine-like actions, rats were trained to discriminate (+)-amphetamine sulphate in a standard two lever operant drug discrimination (DD) procedure using a fixed ratio 10 schedule of food reinforcement with a quantal, lever selection, index of the amphetamine stimulus. The 'training' dose of amphetamine was 1 mg kg-1, i.p. Rats trained with this dose of amphetamine (n = 15) learned the drug discrimination rapidly over 30 training sessions and discriminative performance in these animals was subsequently maintained at a high level of accuracy (90% correct) over a prolonged time. In tests in these trained animals, amphetamine itself and the antidepressant agents nomifensine and tranylcypromine all produced clear, unequivocal dose-related generalization to amphetamine with ED50s of 0.2, 0.5 and 1.6 mg kg-1 respectively (as determined by probit analyses). In tests with paroxetine hydrochloride it was established that, over the dose range 0.3 to 10 mg kg-1, no evidence was seen of generalization to the amphetamine stimulus. These data confirm earlier studies which suggested that some antidepressants may possess abuse potential because of their ability to induce amphetamine-like internal states. In contrast, paroxetine is devoid of such properties.