Successful de-implementation of an ineffective practice: The fall of docusate

BACKGROUND

Reducing wasteful practices optimizes value in medicine. Docusate lacks treatment efficacy yet is widely prescribed. This quality improvement project aimed to de-implement docusate in place of a new evidence-based order set.

METHODS

This is an ambidirectional study of inpatient laxative orders from 2018 to 2022 ​at one institution. We stratified docusate data by service/unit to target prospective deimplementation initiatives. A new evidence-based constipation order set was embedded in Cerner.

RESULTS

There were 701,732 docusate orders across 75 services on 68 units. Top docusate ordering services were Trauma, Obstetrics and Hospitalist. Docusate administration rates were higher than for other laxatives. Our efforts reduced docusate orders by 44% over 4 months. PEG and senna orders increased by 58% and 35%.

CONCLUSION

Docusate has no efficacy yet is widely prescribed. A structured de-implementation strategy can drive systematic change by leveraging technology and applying multidisciplinary improvement efforts. Our work removed docusate from the inpatient formulary.

A Quality Improvement Approach to Decrease the Utilization of Docusate in Hospitalized Patients

BACKGROUND AND OBJECTIVES

Docusate sodium is a commonly prescribed medication to relieve constipation, but several studies have demonstrated its ineffectiveness. Its continued use in the hospital setting adds unnecessary cost and risk to patients. At the Mayo Clinic Florida campus, docusate was ordered for 9.7% of patients admitted to the internal medicine resident (IMED) teaching services during the month of January 2020, and the average hospital length of stay (LOS) was 3.1 days.

METHODS

A multidisciplinary team of internal medicine resident physicians and pharmacists collaborated to address this quality gap through a quality improvement project. It sought to reduce the number of patients admitted to the IMED teaching services who had an order placed for docusate by 50% in less than 6 months without adversely impacting hospital LOS. Two separate interventions were devised using Six Sigma methodology and implemented to reduce the frequency of docusate orders, which involved educating internal medicine residents and hospital pharmacists, and creating an additional process-related barrier to docusate orders.

RESULTS

The percentage of docusate orders decreased from 9.7% to 2.4% ( P = .004) with a grossly unchanged LOS of 3.1 days to 2.7 days ( P = .12) after 5 weeks.

CONCLUSION

The implementation of a dual-pronged intervention successfully decreased the use of an ineffective medication in hospitalized patients without impacting the balancing measure, and serves as a model that can be adopted at other institutions with the hope of promoting evidence-based medical care.

Efficacy of One Dose of Laxative on Postoperative Constipation Following Total Knee Arthroplasty

Postoperative constipation is a common problem among orthopaedic surgical patients leading to discomfort, increased length of stay, and other complications. The primary purpose of this study was to determine the effectiveness of polyethylene glycol compared with docusate sodium for the prevention of constipation, after total knee arthroplasty. The secondary purpose was to examine the effectiveness of polyethylene glycol on pain and strain with bowel movement. A two-group nonequivalent cohort design was used to evaluate the effect of one 17-g dose of polyethylene glycol by mouth on postoperative day 1 compared with usual care with docusate sodium 100 mg starting the day of surgery and continued twice daily at home. There was no significant difference in the rate of constipation between the two cohorts in the 3 days after surgery. There was no difference in reported pain and strain. Future research should focus on the use of pharmacologic and nursing interventions together for prevention of postoperative constipation in patients with arthroplasty surgery.

Chronic Constipation in the United States: Results From a Population-Based Survey Assessing Healthcare Seeking and Use of Pharmacotherapy

OBJECTIVES

Chronic idiopathic constipation (CIC) is characterized by unsatisfactory defecation and difficult or infrequent stools. CIC affects 9%-20% of adults in the United States, and although prevalent, gaps in knowledge remain regarding CIC healthcare seeking and medication use in the community. We recruited a population-based sample to determine the prevalence and predictors of (i) individuals having discussed their constipation symptoms with a healthcare provider and (ii) the use of constipation therapies.

METHODS

We recruited a representative sample of Americans aged 18 years or older who had experienced constipation. Those who met the Rome IV criteria for irritable bowel syndrome and opioid-induced constipation were excluded. The survey included questions on constipation severity, healthcare seeking, and the use of constipation medications. We used multivariable regression methods to adjust for confounders.

RESULTS

Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria). Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%). Age, sex, race/ethnicity, marital status, employment status, having a source of usual care, insurance status, comorbidities, locus of control, and constipation severity were associated with seeking care (P < 0.05). Overall, 47.8% of respondents were taking medication to manage their constipation: over-the-counter medication(s) only, 93.5%; prescription medication(s) only, 1.3%; and both over-the-counter medication(s) and prescription medication(s), 5.2%.

DISCUSSION

We found that 3 of 5 Americans with constipation have never discussed their symptoms with a healthcare provider. Furthermore, the use of prescription medications for managing constipation symptoms is low because individuals mainly rely on over-the-counter therapies.

Ear drops for the removal of ear wax

BACKGROUND

Ear wax (cerumen) is a normal bodily secretion that can become a problem when it obstructs the ear canal. Symptoms attributed to wax (such as deafness and pain) are among the commonest reasons for patients to present to primary care with ear trouble.Wax is part of the ear's self-cleaning mechanism and is usually naturally expelled from the ear canal without causing problems. When this mechanism fails, wax is retained in the canal and may become impacted; interventions to encourage its removal may then be needed. Application of ear drops is one of these methods. Liquids used to remove and soften wax are of several kinds: oil-based compounds (e.g. olive or almond oil); water-based compounds (e.g. sodium bicarbonate or water itself); a combination of the above or non-water, non-oil-based solutions, such as carbamide peroxide (a hydrogen peroxide-urea compound) and glycerol.

OBJECTIVES

To assess the effects of ear drops (or sprays) to remove or aid the removal of ear wax in adults and children.

SEARCH METHODS

We searched the Cochrane ENT Trials Register; Cochrane Register of Studies; PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 March 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which a 'cerumenolytic' was compared with no treatment, water or saline, an alternative liquid treatment (oil or almond oil) or another 'cerumenolytic' in adults or children with obstructing or impacted ear wax.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were 1) the proportion of patients (or ears) with complete clearance of ear wax and 2) adverse effects (discomfort, irritation or pain). Secondary outcomes were: extent of wax clearance; proportion of people (or ears) with relief of symptoms due to wax; proportion of people (or ears) requiring further intervention to remove wax; success of mechanical removal of residual wax following treatment; any other adverse effects recorded and cost. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 10 studies, with 623 participants (900 ears). Interventions included: oil-based treatments (triethanolamine polypeptide, almond oil, benzocaine, chlorobutanol), water-based treatments (docusate sodium, carbamide peroxide, phenazone, choline salicylate, urea peroxide, potassium carbonate), other active comparators (e.g. saline or water alone) and no treatment. Nine of the studies were more than 15 years old.The overall risk of bias across the 10 included studies was low or unclear.

PRIMARY OUTCOME

proportion of patients (or ears) with complete clearance of ear waxSix studies (360 participants; 491 ears) contributed quantitative data and were included in our meta-analyses.Active treatment versus no treatmentOnly one study addressed this comparison. The proportion of ears with complete clearance of ear wax was higher in the active treatment group (22%) compared with the no treatment group (5%) after five days of treatment (risk ratio (RR) 4.09, 95% confidence interval (CI) 1.00 to 16.80); one study; 117 ears; NNTB = 8) (low-quality evidence).Active treatment versus water or salineWe found no evidence of a difference in the proportion of patients (or ears) with complete clearance of ear wax when the active treatment group was compared to the water or saline group (RR 1.47, 95% CI 0.79 to 2.75; three studies; 213 participants; 257 ears) (low-quality evidence). Two studies applied drops for five days, but one study only applied the drops for 15 minutes. When we excluded this study in a sensitivity analysis it did not change the result.Water or saline versus no treatmentThis comparison was only addressed in the single study cited above (active versus no treatment) and there was no evidence of a difference in the proportion of ears with complete wax clearance when comparing water or saline with no treatment after five days of treatment (RR 4.00, 95% CI 0.91 to 17.62; one study; 76 ears) (low-quality evidence).Active treatment A versus active treatment BSeveral single studies evaluated 'head-to-head' comparisons between two active treatments. We found no evidence to show that one was superior to any other.Subgroup analysis of oil-based active treatments versus non-oil based active treatmentsWe found no evidence of a difference in this outcome when oil-based treatments were compared with non-oil-based active treatments.

PRIMARY OUTCOME

adverse effects: discomfort, irritation or painOnly seven studies planned to measure and did report this outcome. Only two (141 participants;176 ears) provided useable data. There was no evidence of a significant difference in the number of adverse effects between the types of ear drops in these two studies. We summarised the remaining five studies narratively. All events were mild and reported in fewer than 30 participants across the seven studies (low-quality evidence).Secondary outcomesThree studies reported 'other' adverse effects (how many studies planned to report these is unclear). The available information was limited and included occasional reports of dizziness, unpleasant smell, tinnitus and hearing loss. No significant differences between groups were reported. There were no emergencies or serious adverse effects reported in any of the 10 studies.There was very limited or no information available on our remaining secondary outcomes.

AUTHORS' CONCLUSIONS

Although a number of studies aimed to evaluate whether or not one type of cerumenolytic is more effective than another, there is no high-quality evidence to allow a firm conclusion to be drawn and the answer remains uncertain.A single study suggests that applying ear drops for five days may result in a greater likelihood of complete wax clearance than no treatment at all. However, we cannot conclude whether one type of active treatment is more effective than another and there was no evidence of a difference in efficacy between oil-based and water-based active treatments.There is no evidence to show that using saline or water alone is better or worse than commercially produced cerumenolytics. Equally, there is also no evidence to show that using saline or water alone is better than no treatment.

Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients

CONTEXT

The stool softener docusate is widely used in the management of constipation in hospice patients. There is little experimental evidence to support this practice, and no randomized trials have been conducted in the hospice setting.

OBJECTIVES

To assess the efficacy of docusate in hospice patients.

METHODS

This was a 10-day, prospective, randomized, double-blind, placebo-controlled trial of docusate and sennosides vs. placebo and sennosides in hospice patients in Edmonton, Alberta. Patients were included if they were age 18 years or older, able to take oral medications, did not have a gastrointestinal stoma, and had a Palliative Performance Scale score of 20% or more. The primary outcome measures were stool frequency, volume, and consistency. Secondary outcomes were patient perceptions of bowel movements (difficulty and completeness of evacuation) and bowel-related interventions.

RESULTS

A total of 74 patients were randomized into the study (35 to the docusate group and 39 to the placebo group). There were neither significant differences between the groups in stool frequency, volume, or consistency, nor in difficulty or completeness of evacuation. On the Bristol Stool Form Scale, more patients in the placebo group had Type 4 (smooth and soft) and Type 5 (soft blobs) stool, whereas in the docusate group, more had Type 3 (sausage like) and Type 6 (mushy) stool (P=0.01).

CONCLUSION

There was no significant benefit of docusate plus sennosides compared with placebo plus sennosides in managing constipation in hospice patients. Docusate use should be considered on an individual basis.

The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

The objective of the study was to compare time to first bowel movement (BM) after surgery in subjects randomized to placebo or senna with docusate.

STUDY DESIGN

Ninety-six subjects completed a baseline 7-day bowel diary before and after surgery. After pelvic reconstructive surgery, the subjects were randomized to either placebo (n=45) or senna (8.6 mg) with docusate (50 mg) (n=48). Time to first BM and postoperative use of magnesium citrate were compared.

RESULTS

There was a significant difference in the time to first BM in those receiving senna with docusate vs placebo (3.00+/-1.50 vs 4.05+/-1.50 days; P<.002). More subjects in the placebo group needed to use magnesium citrate to initiate a bowel movement (43.6% vs 7.0%; P<.001).

CONCLUSION

The use of senna with docusate decreases time to first BM in those undergoing pelvic reconstructive surgery compared with placebo. Subjects using senna with docusate are also significantly less likely to use magnesium citrate.

Constipation in people prescribed opioids

INTRODUCTION

Constipation is reported in 52% of people with advanced malignancy. This figure rises to 87% in people who are terminally ill and taking opioids. Constipation may be the most common adverse effect of opioids. There is no reason to believe that people with chronic non-malignant disease who take opioids will be any less troubled by this adverse effect.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: oral laxatives, rectally applied medications, and opioid antagonists for constipation in people prescribed opioids? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: arachis oil enemas, bisacodyl, co-danthrusate/co-danthramer, docusate, glycerol suppositories, ispaghula husk, lactulose, liquid paraffin, macrogols plus electrolyte solutions, magnesium salts, methylcellulose, opioid antagonists, phosphate enemas, senna, sodium citrate micro-enema, and sodium picosulfate.

Can clinical trials requiring frequent participant contact be conducted over the Internet? Results from an online randomized controlled trial evaluating a topical ointment for herpes labialis

Background

The Internet has tremendous appeal for conducting randomized clinical trials and may be especially applicable to trials requiring frequent participant contact. Trials of cold sore remedies, for example, often require daily clinic visits during outbreaks, imposing substantial burden on participants. An Internet-based randomized clinical trial design may reduce this burden, permitting frequent symptom reports with considerably less effort.

Objective

To evaluate the feasibility of a Web-based randomized clinical trial requiring frequent participant interaction, using a 6-month, double-blind, randomized, placebo-controlled pilot trial of a topical ointment containing dioctyl sodium sulfosuccinate (DSS) (Zilex; Meditech Pharmaceuticals, Inc, Scottsdale, Arizona, USA) intended for treatment of recurrent herpes labialis. A secondary objective was to obtain preliminary data on effectiveness outcomes, to assist in planning a fully-powered trial of DSS.

Methods

Adults with physician-confirmed herpes labialis were recruited to apply to the trial. Eligible applicants were randomized to DSS or placebo, mailed to them upon enrolment with instructions to apply topically every 2 hours for the duration of every cold sore outbreak. Participants were instructed to complete online questionnaires at 2-week intervals and, at the initiation of a cold sore, daily "outbreak questionnaires" until outbreak termination. Feasibility outcome measures included trial participant characteristics, frequency of cold sores, participant retention and adherence (to study medication), and data completeness. Treatment effectiveness outcome measures included outbreak duration, days to crust formation, and pain.

Results

Of the 292 individuals applying, 182 screened eligible; 32 participants with confirmed herpes labialis enrolled in the trial. 16 were randomized into the verum group and 16 into the placebo group. 29 (91%) participants completed the trial. During the trial, 34 outbreaks were reported among 23 (72%) participants, resulting in a cold sore incidence rate of 19.8 per 100 person-months of observation. Online data were available for 32 outbreaks; the absence of a resolution date made it impossible to accurately calculate the duration of 12 (38%) outbreaks. Although the DSS treatment group had a shorter mean outbreak duration (6.6 vs 7.7 days, P= .2) and fewer mean days to crust formation (3.5 vs 4.9, P= .1), these differences did not reach statistical significance. The DSS group has statistically significant lower mean pain scores (3.1 vs 7.6, P= .04), but participants in this group also consumed more acetaminophen tablets than the placebo group (1.1 versus 0.5, P=.55). Adherence to medication was similar in both groups: 7 (50%) of the verum group reported using the cream as directed compared to 6 (46.2%) in the placebo group; ( P= .8).

Conclusions

We efficiently recruited participants and achieved high overall retention rates. However, participant adherence to the daily outbreak visit schedules was low and only 7 (50%) participants used the cream as directed. These limitations could be addressed in future Internet-based studies by using Personal Digital Assistants (PDAs), using reminder devices, and providing incentives. By enhancing participant adherence, clinical trials requiring frequent participant contact may be feasible over the Internet.

[Efficacy of Norgalax and Normacol in preparation for examination of the large bowel]

The article contains the results of the prospective non-controlled study of norgalax and normacol enemas in preparation to endoscopic and radiological examinations of the large bowel. The results of investigation showed high effectiveness, simple use of enemas which can be recommended for preparation to examination of and surgery on the large bowel.

Abdominal radiography in monitoring the resolution of sand accumulations from the large colon of horses treated medically

This retrospective study consisted of 14 horses (age 6 weeks-12 years) with radiographically evident sand accumulations cranioventrally in the abdomen and clinical signs suggestive of sand enteropathy. The horses were treated medically and resolution of sand was monitored radiographically. Routine treatment consisted of psyllium mucilloid, combined with magnesium sulphate and/or mineral oilif needed. Initially, the number, size and shape of the sand accumulations showed large variation and the response to therapy was not predictable based on the initial appearance of the accumulation. In 2 foals, some of the sand was passed and the rest was mixed with other intestinal contents within 2-4 days. Even large accumulations disappeared in 2-4 days with psyllium alone or combined with mineral oil in 4 horses. In another 4 horses, the size of the accumulations decreased but varying amounts remained approximately at the same site, despite treatment for 1-4 weeks, and all these horses also had either gastric or large colon impaction. Three horses had a limited response to psyllium treatment, but the accumulation resolved with repeated doses of magnesium sulphate, with or without mineral oil. One horse did not respond to prolonged laxative treatment but the accumulation resolved on pasture. Clinical improvement was not necessarily related to the resolution of sand. Radiography of the cranioventral abdomen was found to be a useful means for monitoring the resolution of sand and confirming the effect of medical treatment in removing sand from the large colon in the horse.

Ceruminolytic effects of docusate sodium: a randomized, controlled trial

STUDY OBJECTIVE

Assessment of the tympanic membrane is often impeded by the presence of cerumen. We compared the ceruminolytic effects of triethanolamine polypeptide and docusate sodium in patients with cerumen.

METHODS

We conducted a prospective, randomized, controlled, double-blind trial on a convenience sample of cooperative adult and pediatric patients presenting to a university-based emergency department who required removal of cerumen to visualize the tympanic membrane. Structured data collection was performed, and the physician determined whether visualization of the tympanic membrane was partially or totally obscured by cerumen (interobserver agreement, rho=0.79). Patients received intra-aural instillation of 1mL of either docusate sodium or triethanolamine polypeptide in a liquid form. If not completely cleared within 15 minutes, the external ear canal was irrigated with 50 or 100 mL of normal saline solution and additional attempts to visualize the tympanic membrane were made. The main outcome was the proportion of ears in which the tympanic membrane could be totally visualized after ceruminolytic instillation with or without irrigation. This study had 80% power to detect a 40% difference between groups in the proportion of totally visualized tympanic membranes (chi(2) test, alpha=.05).

RESULTS

Of 50 enrolled patients, 23 received triethanolamine polypeptide and 27 received docusate sodium. Mean patient age was 40 years (range 1 to 81 years); 35% were female. Groups were similar in age, sex, and proportion of completely obscured tympanic membranes at presentation (78%). The ability to completely visualize the tympanic membrane was significantly greater after treatment with docusate sodium versus triethanolamine polypeptide (81% versus 35%; difference in proportions 47%; 95% confidence interval [CI], 22 to 71) particularly in children aged 5 or less (90% versus 0%; difference in proportions 89%; 95% CI 50 to 100).

CONCLUSION

Docusate sodium solution is a more effective ceruminolytic than triethanolamine polypeptide, allowing complete or partial visualization of the tympanic membrane in most patients after a single application when followed with irrigation. Use of docusate sodium as a ceruminolytic should be encouraged, particularly in children.

Clinical evaluation and management of neurogenic bowel after spinal cord injury

OBJECTIVES

To assess the state of the neurological bowel in spinal cord injured (SCI) patients, design and apply a program for the comprehensive management of neurogenic bowel and evaluate outcome.

SETTING

Out-patient in a Rehabilitation Service.

SUBJECTS

Thirty-eight SCI patients, 12 (32%) with complete lesions of more than 5 years duration.

DESIGN

Observational, longitudinal and prospective. Pre and post intervention.

METHOD

Pre and post SCI intestinal function was evaluated clinically prior to beginning program. The presence of GI symptoms were studied. Laboratory work-up included colonic transit time (CTT), anorectal manometry and recto-colonoscopy. An intestinal program was designed, in order to achieve an effective and efficient evacuation in a predictable and socially acceptable time, to avoid short and long term complications and eliminate inadequate intestinal evacuation habits.

OUTCOME MEASURES

Pre and post SCI difficulty in intestinal evacuation (DIE) was increased (from 2.6% to 26.3%). The most frequent GI symptom was abdominal distention (53%). Colonic inertia was present in 49% of CTT, internal anal sphincter pressure was normal or increased in 77% and rectoanal inhibitory reflex was present in 88%. With the intestinal program, the incidence of DIE was reduced to 8.8%, manual extraction (ME) was reduced from 53% to 37%. Excellent and good results were obtained in 56% of the patients.

CONCLUSION

The proposed intestinal program is effective in the rehabilitation of SCI patients with neurogenic bowel. It is essential to initiate these physiological and safe procedures as soon as possible after sustaining the injury; this will lead to better results and to the elimination of inadequate intestinal maneuvering in the future Spinal Cord (2000) 38, 301 - 308.

How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill

The effectiveness of docusate for constipation has not been studied in the terminally ill. Controversy also exists concerning its effectiveness in the chronically ill. Because chronically ill patients and terminally ill patients have several risk factors for constipation in common, we undertook a systematic review of prospective controlled trials of oral docusate in the chronically ill to clarify the utility of this drug in populations with advanced disease. The data sources were Medline 1966-April 1997, CINAHL 1982-April 1997, Current Contents August 1996-April 1997, Cochrane Library, a hand search of Index Medicus 1940-1966, three palliative care journals, references in relevant articles and texts, and direct contact with experts. Prospective controlled trials evaluating oral docusate in humans with chronic illness and identifiable risk factors for, or preexisting, constipation were selected. Only materials abstracted in English or French were considered. Information was collected by two independent reviewers and included patient demographic data, study design, dose of docusate, outcomes of stool consistency, stool frequency, need for other laxatives, and assessment of methodologic and reporting quality. Of nine identified studies, four were eligible. These incorporated three different designs and sample sizes that ranged from 15 to 74. Quality assessment scores were low (range 0.46-0.52 with a perfect score being 1.0). Three studies were flawed in blinding of treatment allocation and the use of co-interventions. All studies showed a small trend toward increased stool frequency on docusate. Because of significant clinical heterogeneity in the identified studies, pooled data analysis was not feasible. At present, the use of docusate for constipation in palliative care is based on inadequate experimental evidence. Randomized controlled trials with chronically ill patients and patients with advanced disease are needed to determine its role in prevention and treatment of constipation.

[Common gastrointestinal symptoms and their effective and safe treatment]

The pharmacist is an important specialist in the selection of the drug when the patient comes for pharmacist's advice of how to alleviate common gastrointestinal symptoms. Of all drugs which can be effective in these situations, only three drugs (bismuth subsalicylate, psyllium, and docusate sodium) proved to be advantageous for self-medication. Bismuth subsalicylate (BSS) is much appreciated in the treatment of peptic ulcers where it not only covers the base of the ulcer but also eradicates Helicobacter pylori. Therefore this drug does not treat only the symptoms but the cause of the disease as well. Dyspepsia may also be effectively treated with BSS because of its strong and rapid protective effect on the gastric mucosa. Last but not least, the salicylate component of this substance and not bismuth alone is responsible for the elimination of diarrhoea in the so-called traveller's diarrhoea, as the salicylate decreases enhanced secretion of fluid in the colon. On the other hand, the natural fibre psyllium may effectively alleviate constipation, because it increases the volume and weight of stools as well as the transit time in the colon and facilitates defecation. Similarly, docusate sodium is a detergent agent which facilitates the entrance of water into the stool, which is then better and more easily pushed out from the large intestine.

Psyllium is superior to docusate sodium for treatment of chronic constipation

BACKGROUND

Stool softening is a physician's first step in the management of chronic constipation.

AIM

To compare stool softening (stool water content) and laxative efficacy of psyllium hydrophilic mucilloid vs. docusate sodium.

METHODS

The multi-site, randomized, double-blind, parallel-design study of 170 subjects with chronic idiopathic constipation involved a 2-week baseline (placebo) phase followed by 2 weeks of treatment. The treatment phase compared psyllium (5.1 g b.d.) plus docusate placebo to docusate sodium (100 mg b.d.) plus psyllium placebo. Stools were collected and assessed.

RESULTS

Compared to baseline, psyllium increased stool water content vs. docusate (psyllium 2.33% vs. docusate 0.01%, P = 0.007). Psyllium also increased stool water weight (psyllium 84.0 g/BM; docusate 71.4 g/BM; P = 0.04), total stool output (psyllium 359.9 g/week: docusate 271.9 g/week; P = 0.005), and O'Brien rank-type score combining objective measures of constipation (psyllium 475.1; docusate 403.9; P = 0.002). Bowel movement (BM) frequency was significantly greater for psyllium (3.5 BM/week) vs. docusate (2.9 BM/week) in treatment week 2 (P = 0.02), with no significant difference (P > 0.05) between treatment groups in treatment week 1 (3.3 vs. 3.1 BM/week).

CONCLUSION

Psyllium is superior to docusate sodium for softening stools by increasing stool water content, and has greater overall laxative efficacy in subjects with chronic idiopathic constipation.

Bowel care for individuals with spinal cord injury: comparison of four approaches

The efficacies of four bowel care regimens (bisacodyl suppositories, glycerin suppositories, mineral oil enemas and docusate sodium mini-enemas) were compared in seven subjects with traumatic spinal cord injury. Efficacy was assessed in terms of colonic transit time, bowel evacuation time and subjective responses to a questionnaire. Both docusate sodium mini-enemas and mineral oil enemas decreased total and left-sided colonic transit time. However, docusate sodium mini-enemas were superior to mineral oil enemas in terms of the decrease in bowel evacuation time and symptom reduction. Results in this small group of subjects suggest that docusate sodium mini-enemas may have advantages in the management of bowel evacuation in individuals with spinal cord injury.

The effects of four, commercial ceruminolytic agents on the middle ear

Four, commercially available ceruminolytic agents and physiological saline were screened for ototoxic and inflammatory reactions on the middle ear mucosae of guinea pigs (n = 38) and dogs (n = 24). Each solution was injected transtympanically in anesthetized animals. The effects were assessed by brain stem auditory evoked response (BAER) tests to evaluate hearing function and by histological examination of the middle ear structures. Varying degrees of hearing loss and inflammation were observed in some guinea pigs and dogs treated with solutions A, C, and D, whereas no abnormal finding was associated with solution B or saline.

A comparison of the effectiveness of Therevac SB and bisacodyl suppositories in SCI patients' bowel programs

The evaluation described in this article compared the Therevac SB "mini-enema" with bisacodyl suppositories in the bowel management programs of patients with spinal cord injury (SCI). Of particular interest were (a) determining whether the additional costs of Therevac SB could be justified and (b) identifying the degree of bowel program improvement possible. Fourteen SCI patients were selected from the SCI inpatient unit and the clinic of a Department of Veterans Affairs facility. All patients experienced a delay of at least 45 minutes between insertion of a suppository and the beginning of stool evacuation. Each patient used bisacodyl suppositories for five bowel programs, then Therevac SB for five programs, finally repeating the bisacodyl suppositories for five more programs. Each patient maintained a bowel program log. Ten patients completed the evaluation. Using a MANOVA, the authors found a significant difference between bisacodyl and Therevac SB mean evacuation times for this group. An analysis of direct and indirect costs related to bowel care with the two regimens is also presented.

A nonprescription cerumenolytic

Cerumen impaction and removal is a very common otologic problem. The perfect cerumenolytic agent has yet to be developed. After years of trying multiple different cerumenolytics without satisfaction, a stool softener, docusate sodium, has become our agent of choice. A commonly used stool softener, it is widely available without prescription. It is a highly effective cerumenolytic, but remains relatively unknown in this capacity.

Leiomyoma of the small colon in a horse

A leiomyoma of the small colon was discovered incidentally in a 4-year-old Thoroughbred gelding during colic surgery to correct large colon displacement. The mass and 20 cm of small colon were resected, and an end-to-end anastomosis was performed. A postoperative fecal impaction proximal to the anastomosis responded after 5 days to administration of intravenous fluids, analgesics, and stool softeners.

Effect of oral dioctyl sodium sulfosuccinate on intake-output studies of human small and large intestine

Dioctyl sodium sulfosuccinate (DSS) is an anionic detergent that is used widely as a laxative and promoted as a stool softener. Although many anecdotal reports attest to the laxative and stool softening efficacy of DSS, no controlled trials have been performed to document the effect of DSS on small or large bowel function in humans. We have compared, therefore, the effects of 100 mg of DSS three times daily (the maximum recommended dose) with placebo in a randomized, single blind, crossover study in two groups of subjects. First, 6 healthy ileostomates were studied while they ate a constant diet for 8 days. Dioctyl sodium sulfosuccinate administered for 4 days did not increase the daily ileal output of carbohydrate, total fatty acids, bile acids, nitrogen, or water. Cholesterol excretion was decreased while taking DSS (p less than 0.05). Second, 6 healthy volunteers were studied while eating a constant diet of 20 g of fiber plus 30 radiopaque markers daily so that mean daily transit time could be measured. After equilibration, a 7-day collection of stool was weighed and lyophylized to measure fecal water. Dioctyl sodium sulfosuccinate had no effect on stool weight, stool frequency, stool water, or mean transit time. We conclude that 300 mg/day of DSS does not increase ileal or colonic output of solids or water in healthy human subjects.

Abomasal impaction in sheep

Abomasal engorgement was diagnosed in five Suffolk rams and one Suffolk ewe. All sheep had poor or no appetite for between seven days and five months duration. They were depressed, thin and weak. Rectal temperature and respiration rates were within the normal range. Pulse rate was increased (97.6 +/- 11.55/minute, mean +/- se). A distended abdomen was present and, or, a firm mass was ballotted or palpated in the lower right abdomen. Rumen motility was increased and contractions were strong. Laparotomy revealed enlarged abomasums in four sheep. Enlarged abomasums were found at necropsy in two sheep. Abomasal contents resembled rumen ingesta in character and odour. Removal of ingesta by abomasotomy produced temporary improvement in three rams for six to 12 weeks. All six sheep died or were euthanased.

Regulation of bowel function by a laxative/stool softener preparation in aged nursing home patients

A 12-week program for 42 chronically constipated patients in a nursing home involved a graduated dosage regimen of standardized senna concentrate with dioctyl sodium sulfosuccinate (Senokot-S Tablets), a high-fiber diet, and an increased fluid intake. The program achieved a satisfactory pattern of bowel evacuation in 36 (86 percent) of these patients. This pattern, as observed during a 4-week follow-up period while therapy was continued, was characterized by absence of fecal impactions, regular comfortable bowel movements of appropriate consistency, minimal or no straining at stool, and minimal or no resort to enemas. In the initial 2-week control period, none of the 42 patients had responded adequately to only dietary modification and increased hydration. Six additional patients whose response to the control regimen was equivocal, also appeared to benefit from the medication program. Two of these were able to discontinue the laxative tablets completely by the end of the 12-week test period. None of the 48 patients who completed the course experienced any adverse effects related to this rehabilitative program.

Management of postoperative constipation in anorectal surgery

Fifty patients who had undergone proctologic operations were given a combination of standardized senna concentrate and dioctyl sodium sulfosuccinate for prevention or treatment of postoperative constipation. Two Senokot S tablets were given on the evening of the first postoperative day. Patients who had bowel movements after receiving this dose and remained in the hospital received two tablets on each of the following two days. Otherwise, dosage was increased gradually to a maximum of four tablets twice daily until defecation occurred or until the four-day treatment period was over. All patients achieved bowel movements, and in no case was it necessary to administer an enema. No hard stools were passed on the day patients were discharged from the hospital. Overall results were excellent or good in 94 per cent of cases; these results were not affected by age. Ninety-two per cent had bowel movements after the first or second dose was administered. On the day of discharge from the hospital, fecal consistency was satisfactory in 88 per cent of cases and loose in 12 per cent. Except for a single instance of diarrhea after administration of one dose, which involved a patient with a history of loose stools, no side effect occurred during the trial. In view of these responses and the virtual absence of side effects in this study group, Senokot S tablets are judged to be of demonstrated value in the postoperative management of patients undergoing proctologic operations.

Treatment of constipation in geriatric and chronically ill patients: a comparison

The difficulties of adequately managing constipation, particulary in patients with impaired or limited mobility as a result of surgery, cardiovascular or cerebral disease, or advanced age, led us to evaluate the use of stool softeners in a homogeneous group of institutionalized patients. Comparison was made between dioctyl sodium sulfosuccinate (DSS) (Colace), q.d. and b.i.d., and dioctyl calcium sulfosuccinate (DCS) (Surfak), q.d. Analysis of results showed 81% of the patients receiving DCS improved, a significant result (P is less than .02) when assessed by the sign test. By contrast, DSS caused no significant improvement over placebo, regardless of whether it was administered once or twice a day. The mean number of natural bowel movements among the DCS group increased approximately 62% over the placebo period, more than twice the 30% increase seen with DSS administered either b.i.d. or q.d. No adverse reactions were reported in any of the groups, and no significant study-induced changes occurred in laboratory measurements.