Lower urinary tract symptoms in men: the TRIUMPH cluster RCT

Background

Conservative therapies are recommended as initial treatment for male lower urinary tract symptoms. However, there is a lack of evidence on effectiveness and uncertainty regarding approaches to delivery.

Objective

The objective was to determine whether or not a standardised and manualised care intervention delivered in primary care achieves superior symptomatic outcome for lower urinary tract symptoms to usual care.

Design

This was a two-arm cluster randomised controlled trial.

Setting

The trial was set in 30 NHS general practice sites in England.

Participants

Participants were adult men (aged ≥ 18 years) with bothersome lower urinary tract symptoms.

Interventions

Sites were randomised 1 : 1 to deliver the TReatIng Urinary symptoms in Men in Primary Health care using non-pharmacological and non-surgical interventions trial intervention or usual care to all participants. The TReatIng Urinary symptoms in Men in Primary Health care using non-pharmacological and non-surgical interventions intervention comprised a standardised advice booklet developed for the trial from the British Association of Urological Surgeons' patient information sheets, with patient and expert input. Patients were directed to relevant sections by general practice or research nurses/healthcare assistants following urinary symptom assessment, providing the manualised element. The healthcare professional provided follow-up contacts over 12 weeks to support adherence to the intervention.

Main outcome measures

The primary outcome was the validated patient-reported International Prostate Symptom Score 12 months post consent. Rather than the minimal clinically important difference of 3.0 points for overall International Prostate Symptom Score, the sample size aimed to detect a difference of 2.0 points, owing to the recognised clinical impact of individual symptoms.

Results

A total of 1077 men consented to the study: 524 in sites randomised to the intervention arm (n = 17) and 553 in sites randomised to the control arm (n = 13). A difference in mean International Prostate Symptom Score at 12 months was found (adjusted mean difference of -1.81 points, 95% confidence interval -2.66 to -0.95 points), with a lower score in the intervention arm, indicating less severe symptoms. Secondary outcomes of patient-reported urinary symptoms, quality of life specific to lower urinary tract symptoms and perception of lower urinary tract symptoms all showed evidence of a difference between the arms favouring the intervention. No difference was seen between the arms in the proportion of urology referrals or adverse events. In qualitative interviews, participants welcomed the intervention, describing positive effects on their symptoms, as well as on their understanding of conservative care and their attitude towards the experience of lower urinary tract symptoms. The interviews highlighted that structured, in-depth self-management is insufficiently embedded within general practitioner consultations. From an NHS perspective, mean costs and quality-adjusted life-years were similar between trial arms. The intervention arm had slightly lower mean costs (adjusted mean difference of -£29.99, 95% confidence interval -£109.84 to £22.63) than the usual-care arm, and a small gain in quality-adjusted life-years (adjusted mean difference of 0.001, 95% confidence interval -0.011 to 0.014).

Conclusions

The intervention showed a small, sustained benefit for men's lower urinary tract symptoms and quality of life across a range of outcome measures in a UK primary care setting. Qualitative data showed that men highly valued the intervention. Intervention costs were marginally lower than usual-care costs. Limitations of the study included that trial participants were unmasked, with limited diversity in ethnicity and deprivation level. Additional research is needed to assess the applicability of the intervention for a more ethnically diverse population..

Trial registration

This trial is registered as ISRCTN11669964.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/90/03) and is published in full in Health Technology Assessment; Vol. 28, No. 13. See the NIHR Funding and Awards website for further award information.

Cost-effectiveness of a primary healthcare intervention to treat male lower urinary tract symptoms: the TRIUMPH cluster randomised controlled trial

OBJECTIVES

To estimate the cost-effectiveness of a primary care intervention for male lower urinary tract symptoms (LUTS) compared with usual care.

DESIGN

Economic evaluation alongside a cluster randomised controlled trial from a UK National Health Service (NHS) perspective with a 12-month time horizon.

SETTING

Thirty NHS general practice sites in England.

PARTICIPANTS

1077 men aged 18 or older identified in primary care with bothersome LUTS.

INTERVENTIONS

A standardised and manualised intervention for the treatment of bothersome LUTS was compared with usual care. The intervention group (n=524) received a standardised information booklet with guidance on conservative treatment for LUTS, urinary symptom assessment and follow-up contacts for 12 weeks. The usual care group (n=553) followed local guidelines between general practice sites.

MEASURES

Resource use was obtained from electronic health records, trial staff and participants, and valued using UK reference costs. Quality-adjusted life-years (QALYs) were calculated from the EQ-5D-5L questionnaire. Adjusted mean differences in costs and QALYs and incremental net monetary benefit were estimated.

RESULTS

866 of 1077 (80.4%) participants had complete data and were included in the base-case analysis. Over the 12-month follow-up period, intervention and usual care arms had similar mean adjusted costs and QALYs. Mean differences were lower in the intervention arm for adjusted costs -£29.99 (95% CI -£109.84 to £22.63) while higher in the intervention arm for adjusted QALYs 0.001 (95% CI -0.011 to 0.014). The incremental net monetary benefit statistic was £48.01 (95% CI -£225.83 to £321.85) at the National Institute for Health and Care Excellence UK threshold of £20 000 per QALY. The cost-effectiveness acceptability curve showed a 63% probability of the intervention arm being cost-effective at this threshold.

CONCLUSIONS

Costs and QALYs were similar between the two arms at 12 months follow-up. This indicates that the intervention can be implemented in general practice at neutral cost.

TRIAL REGISTRATION NUMBER

ISRCTN11669964.

Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: cluster randomised controlled trial

OBJECTIVE

To determine whether a standardised and manualised care intervention in men in primary care could achieve superior improvement of lower urinary tract symptoms (LUTS) compared with usual care.

DESIGN

Cluster randomised controlled trial.

SETTING

30 National Health Service general practice sites in England.

PARTICIPANTS

Sites were randomised 1:1 to the intervention and control arms. 1077 men (≥18 years) with bothersome LUTS recruited between June 2018 and August 2019: 524 were assigned to the intervention arm (n=17 sites) and 553 were assigned to the usual care arm (n=13 sites).

INTERVENTION

Standardised information booklet developed with patient and expert input, providing guidance on conservative and lifestyle interventions for LUTS in men. After assessment of urinary symptoms (manualised element), general practice nurses and healthcare assistants or research nurses directed participants to relevant sections of the manual and provided contact over 12 weeks to assist with adherence.

MAIN OUTCOME MEASURES

The primary outcome was patient reported International Prostate Symptom Score (IPSS) measured 12 months after participants had consented to take part in the study. The target reduction of 2.0 points on which the study was powered reflects the minimal clinically important difference where baseline IPSS is <20. Secondary outcomes were patient reported quality of life, urinary symptoms and perception of LUTS, hospital referrals, and adverse events. The primary intention-to-treat analysis included 887 participants (82% of those recruited) and used a mixed effects multilevel linear regression model adjusted for site level variables used in the randomisation and baseline scores.

RESULTS

Participants in the intervention arm had a lower mean IPSS at 12 months (adjusted mean difference -1.81 points, 95% confidence interval -2.66 to -0.95) indicating less severe urinary symptoms than those in the usual care arm. LUTS specific quality of life, incontinence, and perception of LUTS also improved more in the intervention arm than usual care arm at 12 months. The proportion of urology referrals (intervention 7.3%, usual care 7.9%) and adverse events (intervention seven events, usual care eight events) were comparable between the arms.

CONCLUSIONS

A standardised and manualised intervention in primary care showed a sustained reduction in LUTS in men at 12 months. The mean difference of -1.81 points (95% confidence interval -0.95 to -2.66) on the IPSS was less than the predefined target reduction of 2.0 points.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN11669964.

A qualitative study of continence service provision for people living with dementia at home in the UK: Still inadequate?

Introduction

Incontinence is a major problem for people with dementia (PWD) and their family/friend caregivers, often causing substantial harm, including residential care admission. The incontinence needs of PWD are complex and different from those of people without dementia.

The aim of this study was to investigate carer and nurse perceptions of continence service provision and potential improvements.

Methods

A secondary analysis of qualitative data was undertaken. Semi-structured interviews (n = 45) were undertaken with PWD, family caregivers and healthcare professionals (continence or dementia nurses) in the UK. PWD and caregivers were recruited via www.joindementiaresearch.nihr.ac.uk and via dementia/carer groups. Nurses were recruited via their employers. Framework analysis was used. The COREQ Research guideline statement assists reporting.

Results

Four themes were found. Firstly, there was a lack of awareness of the service and waiting time. Many caregivers were unaware of continence services and dementia nurses often viewed it as a pad provision service. Caregivers reported long waits not meeting their urgent needs. Secondly, product provision was often inadequate. Most caregivers self-purchased all or many products and substantial variation in product provision was found. The number of products provided was often inadequate. Thirdly, a sense that “nothing can be done” was observed by some nurses and caregivers. Caregivers believed that, if nothing else, care information should be provided. Finally, suggestions for improvements were made, including proactive service signposting, joint clinics with dementia services, improved information before crisis point, dementia training for continence nurses and improved product provision.

Conclusion

Continence service inadequacies for PWD and caregivers have been reported for many years. This study demonstrates service provision remains unsatisfactory in the UK. Stakeholders propose a range of service improvements. It highlights that listening to the voices of PWD, caregivers and nurses is crucial for services seeking to improve continence services for PWD living at home.

A qualitative study and preliminary model of living with dementia and incontinence at home: beyond containment

Background

most people living with dementia (PLWD) will develop incontinence problems with associated harmful consequences. Well-contained incontinence is often the main treatment goal. It would therefore be expected that poorly contained incontinence would have a negative impact.

Aim

to investigate differences in how well-contained or poorly contained incontinence impacts on the experience of living with incontinence for PLWD at home and their carers.

Design

secondary analysis of a qualitative study.

Methods

semi-structured interviews were undertaken with PLWD, carers and healthcare professionals (continence or dementia nurses). PLWD and carers were recruited via www.joindementiaresearch.nihr.ac.uk and via dementia/carer groups. Nurses were recruited via their employers. Interviews were recorded and transcribed verbatim. Framework analysis was used.

Results

forty-five people (twenty-six carers, two PLWD, nine continence nurses and eight dementia nurses) participated. Despite poorly contained incontinence, some PLWD/carer dyads appeared relatively unaffected by incontinence. Conversely, one or both members of some dyads who achieved good containment found incontinence care highly challenging. Four themes were identified, together forming a preliminary model of incontinence containment and impact, as follows:

Conclusion

reliable containment is an important goal for PLWD living at home and their carers, but it is not the only goal. Other factors, such as behaviours that challenge or carer coping strategies, can mean that even well-contained incontinence can have a negative impact. This paper proposes a preliminary model for evaluation.

Problems faced by people living at home with dementia and incontinence: causes, consequences and potential solutions

BACKGROUND

many people living at home with dementia (PLWD) also have poorly managed toilet-use or incontinence problems with damaging consequences for both people with dementia, unpaid carers and healthcare professionals (HCPs). Currently, there are no theoretically or empirically based interventions to help. The underlying causes and subsequent consequences of these problems need to be fully understood in order to support the development of interventions that have the potential to decrease the impact of these problems on people's lives.

AIM

to establish the range of causes, consequences and potential solutions of toilet-use and incontinence problems for PLWD and their carers.

METHOD

a qualitative design was used. Semi-structured interviews were undertaken with PLWD, carers and HCPs (continence or dementia nurses). PLWD and carers were recruited via www.joindementiaresearch.nihr.ac.uk and via dementia/carer groups. Nurses were recruited via their employers. Interviews were digitally recorded and transcribed verbatim. Framework analysis was used to interpret the data to address the goal of the research.

RESULTS

in total, 45 people (26 unpaid carers, 2 people with dementia, 9 continence and 8 dementia HCPs) took part. The causes of toilet-use and incontinence problems were reported to be multi-faceted and complex including those related to dementia (e.g. lack of insight into toileting needs or how to use the toilet), those which are physical (e.g. existing bladder or bowel issues or poor mobility), psychosocial (e.g. inability to ask for help for incontinence) or societal (e.g. fear of stigma), or related to care systems (e.g. lack of expert knowledge) or products (e.g. poor fit or confusing for users). Consequences included harms to physical and mental health, social isolation, increased carer workload and care system resource implications.

CONCLUSION

this study provides the first detailed characterisation of the causes and consequences of and potential solutions for incontinence problems for PLWD at home and their carers. Multifaceted and complex problems were identified, layering dementia, physical, psychosocial, societal and care system factors and highlighting contextual variation. This new knowledge provides the essential basis for the (now underway) development of urgently needed practical and implementable interventions for this underserved population.

An effective evidence-based cleaning method for the safe reuse of intermittent urinary catheters: In vitro testing

AIMS

To determine a safe bactericidal cleaning method that does not damage urethral catheters used for intermittent catheterization. In some countries, single-use catheters are the norm; in others, the reuse of catheters is common depending on health insurance, personal preference, or individual concerns about the environment. However, no recent study of cleaning methods has been published to provide evidence for the safe reuse of catheters.

METHODS

Using advanced microbiological methods, a laboratory study of eight cleaning methods was conducted. Sections of uncoated polyvinylchloride (PVC) catheters were exposed to bacterial uropathogens in physiologically correct artificial urine media then tested with a range of heat, chemical, and mechanical cleaning methods. Analysis of culturable and viable but nonculturable (VBNC) bacteria was done and direct microscopy was used. Descriptive statistics were used to compare values.

RESULTS

Heat treatments, although effective, resulted in catheter surface breakdown and damage. Ultrasonic cleaning and vinegar showed evidence of VBNC populations indicating the methods were bacteriostatic. Detergent and water wash followed by immersion in a commercially available 0.6% sodium hypochlorite solution and 16.5% sodium chloride (diluted Milton) gave consistent bactericidal results and no visible catheter damage.

CONCLUSIONS

Combined mechanical and chemical treatment of a detergent and water wash followed by immersion in diluted Milton (the "Milton Method") provided consistent and effective cleaning of uncoated PVC catheters, showing bactericidal action for all uropathogens tested after repeated exposure. If found safe in clinical testing, this method could increase the reuse of catheters, reduce plastic waste in the environment, reduce cost, and increase patient choice.

TReatIng Urinary symptoms in Men in Primary Healthcare using non-pharmacological and non-surgical interventions (TRIUMPH) compared with usual care: study protocol for a cluster randomised controlled trial

BACKGROUND

Lower urinary tract symptoms (LUTS) can relate to urinary storage or voiding. In men, the prevalence and severity of LUTS increases with age, with a significant impact on quality of life. The majority of men presenting with LUTS are managed by their general practitioner (GP) in the first instance, with conservative therapies recommended as the initial treatment. However, the provision of conservative therapies in primary care is variable and can be time and resource limited. GPs require practical resources to enhance patient engagement with such interventions. TRIUMPH aims to determine whether a standardised and manualised care intervention delivered in primary care achieves superior symptomatic outcome for LUTS versus usual care.

METHODS/DESIGN

TRIUMPH is a two-arm, cluster randomised controlled trial (RCT) being conducted in 30 National Health Service (NHS) general practices in England. The TRIUMPH intervention comprises a standardised LUTS advice booklet developed for the trial with patient and healthcare professional (HCP) consultation. The booklet is delivered to patients by nurses/healthcare assistants following assessment of their urinary symptoms. Patients are directed to relevant sections of the booklet, providing the manualised element of the intervention. To encourage adherence, HCPs provide follow-up contacts over 12 weeks. Practices are randomised 1:1 to either deliver the TRIUMPH intervention or a usual care pathway. The patient-reported International Prostate Symptom Score (IPSS) at 12 months post consent is the primary outcome. Secondary outcomes include cost-effectiveness, patient-reported outcomes on LUTS, quality of life, and patient and HCP acceptability and experience of the intervention. Primary analyses will be conducted on an intention-to-treat basis.

DISCUSSION

It is unclear whether conservative therapies for male LUTS are effectively delivered in primary care using current approaches. This can lead to men being inappropriately referred to secondary care or experiencing persistent symptoms. Primary care, therefore, holds the key to effective treatment for these men. The TRIUMPH intervention, through its standardised and manualised approach, has been developed to support GP practices in delivering effective conservative care. This pragmatic, cluster RCT should provide robust evidence in a primary-care setting to inform future guidelines.

TRIAL REGISTRATION

ISCRTN registry, ID: ISRCTN11669964 . Registered on 12 April 2018.

Tissue response to applied loading using different designs of penile compression clamps

Background: Penile compression devices (PCD) or clamps are applied to compress the urethra and prevent urinary incontinence (UI). PCDs are more secure and less likely to leak than pads, allowing men the opportunity to participate in short-term, vigorous activities. However, they are uncomfortable, can cause pressure ulcers (PU) and affect penile blood flow. No objective assessment of tissue health has been undertaken to assess and compare different PCD designs and to provide guidance on safe use.

Objective: This study was designed to evaluate existing PCDs in terms of their physiological response and potential for pressure-induced injury.

Design, setting and participants: Six men with post-prostatectomy UI tested four selected PCDs at effective pressures, in a random order, in a controlled laboratory setting.

Outcome measurements and statistical analysis: Using objective methods for assessing skin injury, PCDs were measured in situ for their effects on circulatory impedance, interface pressures and inflammatory response.

Results and limitations: There was evidence for PCD-induced circulatory impedance in most test conditions. Interface pressures varied considerably between both PCDs and participants, with a mean value of 137.4±69.7 mmHg. In some cases, penile skin was noted to be sensitive to loading with elevated concentration of the cytokine IL-1α after 10 mins wear, indicating an inflammatory response. IL-1α levels were restored to baseline 40 mins following PCD removal.

Conclusion: Skin health measures indicated tissue and blood flow compromise during the 50 mins of testing using all PCDs. Although there was an elevation in pro-inflammatory cytokines, PCDs did not cause sustained irritation and skin health measures recovered 40 mins after PCD removal. This research indicates that application of a clamp for one hour with an equal clamp free time before reapplication is likely to be safe. Longer periods are often recommended by manufacturers but have yet to be tested.

Use of an occlusive penile clamp during filling cystometry in men with symptoms of stress urinary incontinence

OBJECTIVE

In severe post-prostatectomy stress urinary incontinence (SUI), urodynamics may not identify crucial parameters because of inadequate bladder filling. This study evaluated cystometry and pressure flow studies (PFS) in men in whom severe SUI during attempted filling necessitated application of a penile clamp to allow filling to reach cystometric capacity. Men who had undergone prior radical prostatectomy were identified from a database of patients attending for video urodynamic testing between 2012 and 2017. Symptom scores, bladder diary and free flow rate tests were retrieved. Measurements of the subgroup of men for whom a Thomson-Walker compression clamp was used to enable full urodynamic evaluation were evaluated. 166 patients were identified. In 30 patients (18%), severe SUI led to incomplete filling cystometry. Following application of the penile compression clamp, further filling was achieved in each case. Applying the clamp did not alter vesical filling or impede pressure recording. These men had a lower maximum urethral closure pressure (31.6 vs. 46.5 cm H₂ O; P < 0.001), volume at strong desire to void (132 vs. 242 mL; P = 0.003) and cystometric capacity (226 mL with clamp applied vs. 310 mL; P < 0.001) than the overall post-prostatectomy incontinence population. Flow rates during PFS were comparable, but detrusor pressure at maximum flow was lower in the clamp group (11 vs. 22 cm H₂ O; P = 0.009). A penile clamp applied at the time when leakage becomes excessive during filling cystometry avoids premature test termination in men with severe incontinence.

Reuse of intermittent catheters: a qualitative study of IC users' perspectives

OBJECTIVES

To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters.

DESIGN

Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically.

SETTING

Participant's own homes in Hampshire and Dorset, UK.

PARTICIPANTS

A convenience sample of 39 IC users, aged 23-86 years, using IC for at least 3 months.

RESULTS

The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were advantages. Always having a catheter without fear of 'running out' was considered an advantage of reuse. Some participants were concerned about environmental impact (waste) and cost of single-use catheters. The potential for reuse was usually dependent on location. The analysis showed that often the disadvantages of single-use could be off-set by the advantages of reuse and vice versa, for example, the need to take many single-use catheters on holiday could be addressed by reuse, while the burden of cleaning would be obviated by single-use.

CONCLUSIONS

If shown to be safe with a practical cleaning method, some participants would find reuse an acceptable option, alongside their current single-use method. The choice to use a mixture of single-use and reuse of catheters for different activities (at home, work or holiday) could optimise the perceived advantages and disadvantages of both. The safety and acceptability of such an approach would require testing in a clinical trial.

A trial of devices for urinary incontinence after treatment for prostate cancer

OBJECTIVE

To compare the performance of three continence management devices and absorbent pads used by men with persistent urinary incontinence (>1 year) after treatment for prostate cancer.

PATIENTS AND METHODS

Randomised, controlled trial of 56 men with 1-year follow-up. Three devices were tested for 3 weeks each: sheath drainage system, body-worn urinal (BWU) and penile clamp. Device and pad performance were assessed. Quality of life (QoL) was measured at baseline and follow-up with the King's Health Questionnaire. Stated (intended use) and revealed (actual use) preference for products were assessed. Value-for-money was gathered.

RESULTS

Substantial and significant differences in performance were found. The sheath was rated as 'good' for extended use (e.g. golf and travel) when pad changing is difficult; for keeping skin dry, not leaking, not smelling and convenient for storage and travel. The BWU was generally rated worse than the sheath and was mainly used for similar activities but by men who could not use a sheath (e.g. retracted penis) and was not good for seated activities. The clamp was good for short vigorous activities like swimming/exercise; it was the most secure, least likely to leak, most discreet but almost all men described it as uncomfortable or painful. The pads were good for everyday activities and best for night-time use; most easy to use, comfortable when dry but most likely to leak and most uncomfortable when wet. There was a preference for having a mixture of products to meet daytime needs; around two-thirds of men were using a combination of pads and devices after testing compared with baseline.

CONCLUSIONS

This is the first trial to systematically compare different continence management devices for men. Pads and devices have different strengths, which make them particularly suited to certain circumstances and activities. Most men prefer to use pads at night but would choose a mixture of pads and devices during the day. Device limitations were important but may be overcome by better design.

A multi-centre evaluation of absorbent products for men with light urinary incontinence

AIMS

This study compared the performance of the four main designs of absorbents for men with light incontinence: pouches (shields), leafs (guards), washable pant with integral pad (pantegral), and small disposable pad.

MATERIALS AND METHODS

We did a multiple crossover trial. Men with light urinary incontinence were recruited. All pouches and leafs available in the UK were identified for inclusion. A single pantegral and small pad were selected based on previous evaluations for design comparison. Products were tested in random order for up to 1 week. Performance criteria (e.g., leakage and comfort) were rated using a validated product performance questionnaire. Wet product weights and amount of leakage were recorded in pad leakage diaries. "Overall opinion" for design performance was used as the primary outcome indicator.

RESULTS

Seventy-four men tested six leafs, six pouches, one pantegral, and one small pad. Leakage data was taken from 3,386 wet pads. The pouches generally performed poorly with few significant differences between products. The leafs were more variable with large and significant differences in ratings. Overall the leaf, pantegral, and small pad designs performed significantly better than the pouch (P <or= 0.01) and the pantegral design performed significantly worse than the leaf (P = 0.01). One leaf product was outstanding and performed significantly better than all other designs (P <or= 0.001).

CONCLUSION

This is the first published trial of absorbent products specifically designed for men. Results show that one particular leaf product works best, the pantegral is most suitable only for very light incontinence and the pouches are least successful.

Female urinals for women with impaired mobility

Margaret Macaulay and colleagues describe the range of female urinals currently available, provide guidance on product selection and introduce a novel device designed to overcome some of the limitations of conventional urinals.

A multicenter evaluation of absorbent products for children with incontinence and disabilities

OBJECTIVE

To evaluate all disposable pull-up-style pads (pull-ups) designed for children with learning and or physical disabilities and compare these with a representative sample of disposable diapers (diapers).

DESIGN

A multicenter randomized crossover trial where all children evaluated each product. SETTING AND CHILDREN: A total of 61 community dwelling children with disabilities were recruited from 5 areas throughout the United Kingdom. Families were invited by letter to participate through their local clinical nurse specialist for continence care.

INSTRUMENTS

Instruments used included a range of questionnaires (product performance, design performance, and design preference questionnaires) and pad weight and leakage diaries.

METHODS

The children tested 10 products (5 pull-ups and 5 diapers) for up to 1 week per product both at home and at school. Caregivers (parents and guardians) completed the questionnaires after evaluation of individual products and design groups had been completed. They recorded wet product weights and scored pad leakage at each pad change. School staff completed an abbreviated product performance questionnaire for each product.

RESULTS

There was little difference in the overall performance of the pull-ups compared with the diapers. In the pull-up group, one product performed significantly worse than the others for some performance aspects. Pull-ups worked particularly well for children able to assist with toileting and pad changes. Diapers were liked for ease of changing if the child used calipers, adapted footwear, or trousers. Diapers were more popular than pull-ups for night use, when greater absorbency was required. Neither design performed differently for school or home use. Most caregivers expressed a preference for diapers or pull-ups based on a range of individual needs, for example, level of independence in toileting, discreteness in pad change, fit, and product appearance.

CONCLUSIONS

Diapers and pull-ups have different strengths and limitations, and both meet the specific needs of individual children. Although pull-ups are more expensive than diapers, their use is justified if based on a thorough assessment of individual need.

A Pilot Study to Evaluate Reusable Absorbent Body-Worn Products for Adults With Moderate/Heavy Urinary Incontinence

OBJECTIVE

The purpose of this pilot study was to evaluate the performance of reusable absorbent body-worn products for adults with moderate/heavy urinary incontinence, compare their performance with a group of equivalent disposable products, and establish the need for a larger statistically robust study.

SETTING AND SUBJECTS

Ten men and 4 women living in the community were recruited from locations throughout the United Kingdom.

METHODS

A randomized multiple crossover design was used in which all subjects were given the opportunity to test each product. All the products were available on the UK market in January 2001. The following tools were used in the evaluation: a product performance questionnaire and a pad leakage diary. Overall opinion was used as the primary outcome indicator.

RESULTS

The reusable Paddy T was the best performing product overall, outperforming the disposable products. For low leakage and good absorbency (the most important product attributes identified by the subjects), the disposable all-in-one product performed best during the day. However, the Paddy T performed best for night use. The remaining reusable products performed poorly overall.

CONCLUSIONS

Reusable products for moderate/heavy incontinence remain unpopular for use in isolation. Surprisingly, a product manufactured from terry toweling, a traditional material, performed relatively well. Reusables may provide a useful alternative to disposable products in certain circumstances. The results from this study do not support a more comprehensive costly study.

Disposable pull-ups versus disposable nappies for children with a disability

Most children are expected to be dry by the age of three years (Lukeman, 1997). However, children with physical and/or learning disabilities may have difficulty achieving continence and will have an ongoing need for absorbent products. Historically these were disposable nappies. In recent years, the disposable pull-up style pad (Fig 1) has proved popular as an alternative design.

Are washable absorbents effective at containing urinary incontinence?

This article describes a pilot study to evaluate washable (or reusable) absorbent garments for adults with moderate to heavy urinary incontinence. The article will describe: The study process; How the individual products performed and how the washable and disposable products compared; How nurses can enable their patients to use washable products appropriately.

A simple sequence repeat-based linkage map of barley

A total of 568 new simple sequence repeat (SSR)-based markers for barley have been developed from a combination of database sequences and small insert genomic libraries enriched for a range of short simple sequence repeats. Analysis of the SSRs on 16 barley cultivars revealed variable levels of informativeness but no obvious correlation was found with SSR repeat length, motif type, or map position. Of the 568 SSRs developed, 242 were genetically mapped, 216 with 37 previously published SSRs in a single doubled-haploid population derived from the F(1) of an interspecific cross between the cultivar Lina and Hordeum spontaneum Canada Park and 26 SSRs in two other mapping populations. A total of 27 SSRs amplified multiple loci. Centromeric clustering of markers was observed in the main mapping population; however, the clustering severity was reduced in intraspecific crosses, supporting the notion that the observed marker distribution was largely a genetical effect. The mapped SSRs provide a framework for rapidly assigning chromosomal designations and polarity in future mapping programs in barley and a convenient alternative to RFLP for aligning information derived from different populations. A list of the 242 primer pairs that amplify mapped SSRs from total barley genomic DNA is presented.

Computational and experimental characterization of physically clustered simple sequence repeats in plants

The type and frequency of simple sequence repeats (SSRs) in plant genomes was investigated using the expanding quantity of DNA sequence data deposited in public databases. In Arabidopsis, 306 genomic DNA sequences longer than 10 kb and 36,199 EST sequences were searched for all possible mono- to pentanucleotide repeats. The average frequency of SSRs was one every 6.04 kb in genomic DNA, decreasing to one every 14 kb in ESTs. SSR frequency and type differed between coding, intronic, and intergenic DNA. Similar frequencies were found in other plant species. On the basis of these findings, an approach is proposed and demonstrated for the targeted isolation of single or multiple, physically clustered SSRs linked to any gene that has been mapped using low-copy DNA-based markers. The approach involves sample sequencing a small number of subclones of selected randomly sheared large insert DNA clones (e.g., BACs). It is shown to be both feasible and practicable, given the probability of fortuitously sequencing through an SSR. The approach is demonstrated in barley where sample sequencing 34 subclones of a single BAC selected by hybridization to the Big1 gene revealed three SSRs. These allowed Big1 to be located at the top of barley linkage group 6HS.

Intimate association of microsatellite repeats with retrotransposons and other dispersed repetitive elements in barley

Simple sequence repeat (SSR)-based genetic markers are being actively developed for the majority of crop plant species. In barley, characterization of 290 dinucleotide repeat-containing clones from SSR-enriched libraries has revealed that a high percentage are associated with cereal retrotransposon-like and other dispersed repetitive elements. Associations found were with BARE-1, WIS2-1A, PREM1 and the dispersed repetitive element R173. Additional similarities between different SSR clones, which have no matches in DNA sequence databases, indicate that this phenomenon is probably widespread in the barley genome. Sequence homologies to the non-coding regions of several cereal genes were also explained by homology to mobile genetic elements. The SSRs found can therefore be classified into two types: (1) those with unique sequences on either flank, and (2) those which are intimately associated with retro-transposons and other dispersed repetitive elements. As the cereal genome is thought to consist largely of this type of DNA, some random association would be expected. However, the conserved positions of the SSRs, relative to repetitive elements, indicate that they have arisen non-randomly. Furthermore, this class of SSRs can be classified into three subtypes: (1) those which are positioned 3' of a transposable element with unique sequence on the other flank, (2) those positioned 5' of a transposable element, and (3) those which have arisen from an internal sequence and so have transposable element sequence on both flanks. The first appear to be analogous to the class of SSRs in mammalian systems which are associated with Alu elements and SINEs (short interspersed elements) and which have been postulated to arise following integration of an extended and polyadenylated retro-transcript into the host genome, followed by mutation of the poly(A) tract and expansion into an SSR. For the second, we postulate that a proto-SSR (A-rich sequence) has acted as a 'landing pad' for transposable element insertion (rather than being the result of insertion), while the third includes those which have evolved as a component of an active transposable element which has spread throughout the genome during bursts of transposition activity. The implications of these associations for genome and SSR evolution in barley are discussed.

Discriminating between barley genotypes using microsatellite markers

Eleven microsatellite loci were used to survey 24 barley genotypes representing 23 cultivars and a breeding line in official trials. Three separate combinations of four microsatellites had overall probabilities of identity of less than 1 in 1000 and could distinguish between all 24 barley genotypes. It is shown that the microsatellites could distinguish genotypes with the same pedigree and also that patterns of discrimination were different from those obtained from botanical descriptors. The stability of microsatellites across different generations was demonstrated by a retrospective analysis of the pedigree of Golden Promise. One of the parents of Maythorpe, the immediate ancestor of Golden Promise, was shown to be Irish Goldthorpe rather than Goldthorpe, thereby resolving conflicting published pedigrees.

Extraction and genetic control of two new water-soluble proteins of mature barley seed

This paper describes the genetic control of two new water-soluble proteins in barley. Water-soluble proteins (WSPs) of mature barley seed form part of the albumin/globulin class of seed proteins. They can be extracted from hand-milled grain with water, though some WSPs are more efficiently extracted with a solution of 10 mM dithiothreitol. Polymorphisms for WSPs were detected in isoelectric focusing gels incorporating various ampholine combinations. Two new controlling genes (Wsp4 and Wsp5) have been identified and located using wheat/barley chromosome addition lines and barley doubled haploids. Wsp4 is located on chromosome 2 (2H), and Wsp5 was found to be tightly linked to Wsp2 on the long arm of chromosome 7 (5HL). Segregation of a sixth gene (Wsp6) is also described, but this has not been mapped. The results are discussed with respect to other previously mapped Wsp loci.

Good communication heralds successful integration. Evaluating the roles of community specialist and general nurses

Nurse specialist roles are becoming more prevalent in community care. Do nurse specialists working in the community enable services to provide better care for their patients? How can specialist and general nurses work together to provide optimum holistic care in the community?

Statistical analysis of a linkage experiment in barley involving quantitative trait loci for height and ear-emergence time and two genetic markers on chromosome 4

The quantitative traits height and ear-emergence date were analyzed in the F2 progeny of a cross between a tall winter barley cultivar (Gerbel) and a short spring barley cultivar (Heriot). The trait distributions were found to be related to the genotypes at two biochemical loci, β-amylase (Bmy1) and water-soluble protein (Wsp3), which are known to lie on the long arm of chromosome 4. Linkages between each trait and the markers were investigated using normal mixture models. The two parental phenotypes and the heterozygote phenotype of Bmy1 were distinguishable so the model could be used directly to estimate linkage between Bmy1 and a quantitative trait locus (QTL) for height (Height). The Gerbel homozygote and heterozygote phenotype of Wsp3 could not be distinguished and the model was adapted accordingly. The proportion of plants requiring vernalization was consistent with control by two independent genes acting epistatically, and a normal mixture model based on a two-gene hypothesis was fitted to the distribution of ear-emergence date to estimate linkage between the marker loci and a QTL for ear-emergence date (Vrn1). The parameters of each model were the recombination fraction between the marker locus and the QTL and the means and standard deviations associated with each QTL genotype; these were estimated by maximum likelihood. The fitted distributions correspond well to those observed and the order of the loci along the chromosome is inferred to be Height - Vrn1 - Bmy1 - Wsp3, with Wsp3 being the most distal.