Assessment and management of constipation in post-operative patients in the spinal surgery ward: a best practice implementation project.

INTRODUCTION AND OBJECTIVE: Constipation is a common complication following spinal surgery that can result in distension, abdominal pain, infection, and even intestinal perforation. This study reports on an evidence-based implementation project to reduce the incidence of constipation in spinal surgery wards. METHODS: The project was conducted in the spinal surgery ward of a general tertiary hospital in Changsha City, China, from March to August 2022. We used the JBI Implementation Framework and the JBI Model of Evidence-Based Healthcare for audits and feedback. Data were collected and analyzed using JBI's Practical Application of Clinical Evidence System (PACES) software. Seven audit criteria were developed based on the best practice recommendations summarized by JBI. A baseline audit was conducted with 20 nurses and 50 patients in the spinal surgery ward, and a follow-up audit was conducted using the same sample size and setting. RESULTS: The baseline audit revealed compliance below 46% for five of the seven criteria. Strategies developed to address poor compliance included educating nurses and patients, developing a post-operative constipation risk assessment sheet, organizing stakeholder focus group meetings, establishing a constipation management routine, and effective empowerment of nurses. The follow-up audit showed positive compliance results, with the highest rate for Criterion 7 (100%) and the greatest increase for Criterion 2 (from 0% to 78%). Furthermore, the incidence of post-operative constipation decreased from 48% to 16%. CONCLUSION: The project improved compliance with audit criteria, reduced the incidence of constipation, and enhanced the efficiency of quality management in the spinal surgery ward. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A186.

Assessment of long-term quality of life, bowel and voiding function outcomes in patients with anorectal malformation at a single UK centre.

AIMS: Assess long-term quality of life (QoL), bowel and voiding function in anorectal malformation (ARM) paediatric patients. METHOD: Retrospective review of ARM patients between 2007 and 2020 was performed. QoL (all patients), bowel and voiding function (> 5 yo) were assessed using the paediatric quality of life inventory (PedsQL), paediatric incontinence and constipation score (PICS) and dysfunctional voiding scoring system (DVSS), respectively. RESULTS: There were 122 patients (49% female, 85 > 5 yo) with ARM. Two had died, four refused, twenty-two were non-contactable, leaving ninety-four patients (65 > 5 yo) included. Mean age was 89 months (19-183), and follow-up was 86 months (13-183). Patients had significantly poorer scores for QoL, bowel and voiding function compared to published healthy controls. 57% had poor bowel function, 32% had poor voiding function and 38% required 'ancillary aids' to facilitate function. Patients using 'ancillary aids' for voiding function had a significantly lower QoL (parent: 62 vs 77; p = 0.01, patient: 66 vs 79; p = 0.05). Bowel continence was worse in those with high vs low ARM (13 vs 20, p = 0.004) and timely vs delayed diagnosis (17 vs 24, p = 0.04). CONCLUSION: Patients with ARM have significantly worse QoL, bowel and voiding function than normal healthy controls. There is a need for long-term monitoring of function and further support for these children. LEVEL OF EVIDENCE: III.

Characteristics of constipation screening and assessment tools: a scoping review protocol.

INTRODUCTION: Constipation is a common and significant burden on individuals and healthcare systems. Accurate assessment of constipation severity and symptom improvement are vital aspects of caring for patients with constipation. Therefore, nurses and allied healthcare professionals should possess knowledge regarding the characteristics of constipation assessment tools (ie, aim, scope, definition of constipation, content, structure, mode, administration time and context of use). However, existing reviews summarising characteristics of tools have been restricted to chronic constipation and self-reported measures. Furthermore, they have not included literature published after 2011. This scoping review aims to identify and comprehensibly map the characteristics of available tools for screening and assessment of constipation in order to manage the nursing care need related to constipation within any healthcare or research context and any patient group. METHODS AND ANALYSIS: This review will include primary research articles, methodological papers and clinical guidelines using tools for constipation screening and assessment, pertinent to nursing care management. It is not limited to a specific population or healthcare setting. Databases to be searched include PubMed, Embase, CINAHL, ProQuest, ClinicalKey and Google Scholar. To identify grey literature, national health services in selected countries will be searched. Papers written in English, Nordic language or German will be included. The reviewers will independently review the retrieved citations against the inclusion criteria, and data from included papers will be extracted using a data extraction form developed for this review. The scoping review will be conducted following the Joanna Briggs Institute Guidelines. The results will be presented in a table accompanied by a narrative summary. ETHICS AND DISSEMINATION: Ethical approval is not required, as no individual patient data are included. Findings will be shared and discussed with relevant stakeholders and disseminated through peer-reviewed publications and conference presentations. The protocol is registered on Open Science Framework (registration number: osf.io/h2vzd).

A comparison of the prevalence of dry mouth and other symptoms using two different versions of the Edmonton Symptom Assessment System on an inpatient palliative care unit.

BACKGROUND: Symptom assessment is key to effective symptom management and palliative care for patients with advanced cancer. Symptom prevalence and severity estimates vary widely, possibly dependent on the assessment tool used. Are symptoms specifically asked about or must the patients add them as additional symptoms? This study compared the prevalence and severity of patient-reported symptoms in two different versions of a multi-symptom assessment tool. In one version, three symptoms dry mouth, constipation, sleep problems were among those systematically assessed, while in the other, these symptoms had to be added as an "Other problem". METHODS: This retrospective cross-sectional study included adult patients with advanced cancer at an inpatient palliative care unit. Data were collected from two versions of the Edmonton Symptom Assessment System (ESAS): modified (ESAS-m) listed 11 symptoms and revised (ESAS-r) listed 9 and allowed patients to add one "Other problem". Seven similar symptoms were listed in both versions. RESULTS: In 2013, 184 patients completed ESAS-m, and in 2017, 156 completed ESAS-r. Prevalence and severity of symptoms listed in both versions did not differ. In ESAS-m, 83% reported dry mouth, 73% constipation, and 71% sleep problems, but on ESAS-r, these symptoms were reported by only 3%, 15% and < 1%, respectively. Although ESAS-r severity scores for these three symptoms were higher than on ESAS-m, differences did not reach statistical significance. CONCLUSION: We identified significant differences in patient symptom reporting based on whether symptoms like dry mouth, obstipation and sleep problems were specifically assessed or had to be added by patients as an "Other problem".

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis.

Background: Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective: To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods: Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results: Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review: 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews: studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions: Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration: This study is registered as PROSPERO CRD42019159008. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Between 5% and 30% of children experience constipation at some stage. In one-third of these children, this progresses to chronic functional constipation. Chronic functional constipation affects more children with additional needs. We aimed to find and bring together published information about treatments for chronic functional constipation, to help establish best treatments and treatment combinations. We did not cover assessment or diagnosis of chronic functional constipation. This project was guided by a 'stakeholder group', including parents of children with constipation, people who experienced constipation as children, and healthcare professionals/continence experts. We carried out a 'scoping review' and a series of 'systematic reviews'. Our 'scoping review' provides an overall picture of research about treatments, with 651 studies describing 48 treatments. This helps identify important evidence gaps. 'Systematic reviews' are robust methods of bringing together and interpreting research evidence. Our stakeholder group decided to structure our systematic reviews to reflect who delivered the interventions. We brought together evidence about how well treatments worked when delivered by families/carers (32 studies), the wider children's workforce (e.g. general practitioner, health visitor) (21 studies), continence teams (31 studies) or specialist consultant-led teams (42 studies). We also considered complementary therapies (15 studies) and behavioural strategies (4 studies). Care is affected by what is done and how it is done. We brought together evidence about different models of delivering care (15 studies), barriers and facilitators to implementation of treatments (106 studies) and costs (31 studies). Quality of evidence was mainly low to very low. Despite numerous studies, there was often insufficient information to support generalisable conclusions. Our findings generally agreed with current clinical guidelines. Management of childhood chronic functional constipation should be child-centred, multifaceted and adapted according to the individual child, their needs, the situation in which they live and the health-care setting in which they are looked after. Research is needed to address our identified evidence gaps.

The missing piece of the puzzle - The key role of the dietitian in the management of Parkinson's disease.

The current paradigm for the multidisciplinary management of Parkinson's Disease (PD) does not include regular nutritional assessment despite research showing that 90 % of people living with Parkinson's (PwP) lack access to basic dietetic services. Since many non-motor symptoms such as dysphagia, constipation and orthostatic hypotension and PD complications such as weight loss and sarcopenia can be improved through dietary intervention, dietitians are a critical missing piece of the PD management puzzle. This paper serves to review the role of dietitians and medical nutrition therapy in management of PD as well as a call to action for future studies to investigate improvement of nutritional status and quality of life for all PwP.

Effectiveness, safety and cost-effectiveness of sacral neuromodulation for idiopathic slow-transit constipation: a systematic review.

AIM: Sacral neuromodulation (SNM) is a minimally invasive treatment option for functional constipation. Evidence regarding its effectiveness is contradictory, driven by heterogeneous study populations and designs. The aim of this study was to assess the effectiveness, safety and cost-effectiveness of SNM in children and adults with refractory idiopathic slow-transit constipation (STC). METHOD: OVID Medline, OVID Embase, Cochrane Library, the KSR Evidence Database, the NHS Economic Evaluation Database and the International HTA Database were searched up to 25 May 2023. For effectiveness outcomes, randomized controlled trials (RCTs) were selected. For safety outcomes, all study designs were selected. For cost-effectiveness outcomes, trial- and model-based economic evaluations were selected for review. Study selection, risk of bias and quality assessment, and data extraction were independently performed by two reviewers. For the intervention 'sacral neuromodulation' effectiveness outcomes included defaecation frequency and constipation severity. Safety and cost-effectiveness outcomes were, respectively, adverse events and incremental cost-effectiveness ratios. RESULTS: Of 1390 records reviewed, 67 studies were selected for full-text screening. For effectiveness, one cross-over and one parallel-group RCT was included, showing contradictory results. Eleven studies on safety were included (four RCTs, three prospective cohort studies and four retrospective cohort studies). Overall infection rates varied between 0% and 22%, whereas reoperation rates varied between 0% and 29%. One trial-based economic evaluation was included, which concluded that SNM was not cost-effective compared with personalized conservative treatment at a time horizon of 6 months. The review findings are limited by the small number of available studies and the heterogeneity in terms of study populations, definitions of refractory idiopathic STC and study designs. CONCLUSION: Evidence for the (cost-)effectiveness of SNM in children and adults with refractory idiopathic STC is inconclusive. Reoperation rates of up to 29% were reported.

Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management.

Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.

Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis.

INTRODUCTION: Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population. METHODS: We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity. RESULTS: The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ∼17 patients per year to PFPT, supporting feasibility. DISCUSSION: Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care.

A multiscale assessment of bowel impairment in an Italian multiple sclerosis cohort.

Bowel dysfunctions (BD) in multiple sclerosis (MS) are under reported despite their clinical relevance. Scales usually applied do not thoroughly assess constipation and fecal incontinence. Instead, a proper qualitative and quantitative description of these symptoms might have relevant clinical and scientific consequences. The aim of this project is to study the prevalence of BD in a cohort of persons with MS (pwMS). Four-hundred and forty-seven pwMS (330 relapsing-remitting MS-RRMS and 117 progressive MS-PMS) were recruited. Three different questionnaires were administered: the neurogenic bowel dysfunction score (NBDS), the Wexner constipation scale (WexCon) and the Wexner incontinence scale (WexInc). All the scales were divided in subscores according to symptom severity. The prevalence of BD, considered as NBDS > 0, was 53.7%. Mean scores in pwMS group were as follows: NBDS 2.6 (SD 3.5), WexInc 1.1 (SD 2.4), WexCon 4.4 (SD 5.9). NBDS, WexCon and WexInc were significantly higher in PMS vs RRMS (p < 0.001), and significantly associated with disease duration, EDSS, multiple sclerosis severity score (p < 0.001), as well as with each other (p < 0.001). Our study confirms the presence of bowel dysfunctions in a large group of pwMS with a wide range of disability and their association with progressive disease phenotype and clinical disability.

Importance of Regular Examination and Follow-up in Pediatric Patients with Neurogenic Bladder: 24-Month Follow-up Study Using a Japanese Health Insurance Database.

INTRODUCTION: Data on the long-term management of neurogenic bladder (NGB) are scarce. We evaluated the current status of NGB management in Japanese children over 24-month follow-up using the JMDC database. METHODS: In this descriptive, observational, retrospective cohort study, patients (≤ 17 years) with NGB were included. Patient characteristics and their management status were investigated. A multivariate analysis evaluating the potential risk factors for the development of urinary tract infection (UTI) was performed. The diagnosis of spina bifida, demographics, baseline comorbidities, and early use of clean intermittent catheterization (CIC) and/or overactive bladder (OAB) drugs were used as independent variables. RESULTS: Of 883 eligible children, 39.3% had spina bifida. Over 12/24-month post-index periods, renal urinary tract ultrasound and urinalysis were performed at least once in > 35%/> 45% patients, respectively, while specific tests (urodynamics, cystourethrography, scintigraphy) were performed in substantially fewer (< 11%/< 13%) patients. Over 24 months, 21.5% patients used OAB medications (mostly anticholinergics) and 10.8% underwent CIC, alone or with medications; 1.2% patients underwent surgery. Lower UTI (23.3%), urinary incontinence (9.7%), and hydronephrosis (7.0%) were the most common incident complications. Multivariate analysis evaluating risk factors for UTI showed significantly higher odds ratios with point estimates of ≥ 2 for CIC (5.70), presence of spina bifida (2.86), and constipation (2.07). Overall, urodynamic assessments were inadequately performed. CONCLUSION: Patients with use of CIC and/or having spina bifida and constipation had a higher risk of UTI, suggesting the need for careful follow-up. More guideline-compliant and diligent patient management is necessary in Japanese children with NGB.

Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: A randomized controlled trial.

AIM: The aim was to determine whether specialist-led habit training using Habit Training with Biofeedback (HTBF) is more effective than specialist-led habit training alone (HT) for chronic constipation and whether outcomes of interventions are improved by stratification to HTBF or HT based on diagnosis (functional defaecation disorder vs. no functional defaecation disorder) by radio-physiological investigations (INVEST). METHOD: This was a parallel three-arm randomized single-blinded controlled trial, permitting two randomized comparisons: HTBF versus HT alone; INVEST- versus no-INVEST-guided intervention. The inclusion criteria were age 18-70 years; attending specialist hospitals in England; self-reported constipation for >6 months; refractory to basic treatment. The main exclusions were secondary constipation and previous experience of the trial interventions. The primary outcome was the mean change in Patient Assessment of Constipation Quality of Life score at 6 months on intention to treat. The secondary outcomes were validated disease-specific and psychological questionnaires and cost-effectiveness (based on EQ-5D-5L). RESULTS: In all, 182 patients were randomized 3:3:2 (target 384): HT n = 68; HTBF n = 68; INVEST-guided treatment n = 46. All interventions had similar reductions (improvement) in the primary outcome at 6 months (approximately -0.8 points of a 4-point scale) with no statistically significant difference between HT and HTBF (-0.03 points; 95% CI -0.33 to 0.27; P = 0.85) or INVEST versus no-INVEST (0.22; -0.11 to 0.55; P = 0.19). Secondary outcomes showed a benefit for all interventions with no evidence of greater cost-effectiveness of HTBF or INVEST compared with HT. CONCLUSION: The results of the study at 6 months were inconclusive. However, with the caveat of under-recruitment and further attrition at 6 months, a simple, cheaper approach to intervention may be as clinically effective and more cost-effective than more complex and invasive approaches.

Comparative assessment of efficacy and safety of approved oral therapies for overactive bladder: a systematic review and network meta-analysis.

bladder based on a systematic review and network meta-analysis approach. METHODS: Pubmed, Embase, Web of Science, and the Cochrane Register of Clinical Trials databases were systematically searched. The search time frame was from database creation to June 2, 2022. Randomized controlled double-blind trials of oral medication for overactive bladder were screened against the protocol's entry criteria. Trials were evaluated for quality using the Cochrane Risk of Bias Assessment Tool, and data were statistically analyzed using Stata 16.0 software. RESULT: A total of 60 randomized controlled double-blind clinical trials were included involving 50,333 subjects. Solifenacin 10mg was the most effective in mean daily micturitions and incontinence episodes, solifenacin 5/10mg in mean daily urinary urgency episodes and nocturia episodes, fesoterodine 8mg in urgency incontinence episodes/d and oxybutynin 5mg in voided volume/micturition. In terms of safety, solifenacin 5mg, ER-tolterodine 4mg, mirabegron, vibegron and ER-oxybutynin 10mg all showed a better incidence of dry mouth, fesoterodine 4mg, ER-oxybutynin 10mg, tolterodine 2mg, and vibegron in the incidence of constipation. Compared to placebo, imidafenacin 0.1mg showed a significantly increased incidence in hypertension, solifenacin 10mg in urinary tract infection, fesoterodine 4/8mg and darifenacin 15mg in headache. CONCLUSION: Solifenacin showed better efficacy. For safety, most anticholinergic drugs were more likely to cause dry mouth and constipation, lower doses were better tolerated. The choice of drugs should be tailored to the patient's specific situation to find the best balance between efficacy and safety.

The Burden and Treatment of Chronic Constipation Among US Nursing Home Residents.

OBJECTIVE: To evaluate the burden of chronic constipation (CC) and the use of drugs to treat constipation (DTC) in 2 complementary data sources. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: US nursing home residents aged ≥65 years with CC. METHODS: We conducted 2 retrospective cohort studies in parallel using (1) 2016 electronic health record (EHR) data from 126 nursing homes and (2) 2014-2016 Medicare claims, each linked with the Minimum Data Set (MDS). CC was defined as (1) the MDS constipation indicator and/or (2) chronic DTC use. We described the prevalence and incidence rate of CC and the use of DTC. RESULTS: In the EHR cohort, we identified 25,739 residents (71.8%) with CC during 2016. Among residents with prevalent CC, 37% received a DTC, with an average duration of use of 19 days per resident-month during follow-up. The most frequently prescribed DTC classes included osmotic (22.6%), stimulant (20.9%), and emollient (17.9%) laxatives. In the Medicare cohort, a total of 245,578 residents (37.5%) had CC. Among residents with prevalent CC, 59% received a DTC and slightly more than half (55%) were prescribed an osmotic laxative. Duration of use was shorter (10 days per resident-month) in the Medicare (vs EHR) cohort. CONCLUSIONS AND IMPLICATIONS: The burden of CC is high among nursing home residents. The differences in the estimates between the EHR and Medicare data confirm the importance of using secondary data sources that include over-the-counter drugs and other treatments unobservable in Medicare Part D claims to assess the burden of CC and DTC use in this population.

Analysis of the economic burden of docusate sodium at a United States tertiary care center.

OBJECTIVES: The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate. METHODS: The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed. RESULTS: Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium. CONCLUSION: A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Prevalence and Burden of Illness of Rome IV Chronic Idiopathic Constipation, Opioid-Induced Constipation, and Opioid-Exacerbated Constipation in the United States.

INTRODUCTION: Chronic idiopathic constipation (CIC) and opioid-induced constipation (OIC) are disorders that negatively affect quality of life. We sought to assess the prevalence, symptom severity, and medication use among people with Rome IV CIC, OIC, and opioid-exacerbated constipation (OEC) using a nationally representative data set with nearly 89,000 people in the United States. METHODS: From May 3, 2020, to June 24, 2020, we recruited a representative sample of people in the United States ≥ 18 years to complete an online national health survey. The survey guided participants through the Rome IV CIC and OIC questionnaires, Patient-Reported Outcome Measurement Information System gastrointestinal scales (percentile 0-100; higher = more severe), and medication questions. Individuals with OEC were identified by asking those with OIC whether they experienced constipation before starting an opioid and whether their symptoms worsened afterward. RESULTS: Among the 88,607 participants, 5,334 (6.0%) had Rome IV CIC, and 1,548 (1.7%) and 335 (0.4%) had Rome IV OIC and OEC, respectively. When compared with people with CIC (Patient-Reported Outcome Measurement Information System score, 53.9 ± 26.5; reference), those with OIC (62.7 ± 28.0; adjusted P < 0.001) and OEC (61.1 ± 25.8, adjusted P = 0.048) had more severe constipation symptoms. People with OIC (odds ratio 2.72, 95% confidence interval 2.04-3.62) and OEC (odds ratio 3.52, 95% confidence interval 2.22-5.59) were also more likely to be taking a prescription medication for their constipation vs those with CIC. DISCUSSION: In this nationwide US survey, we found that Rome IV CIC is common (6.0%) while Rome IV OIC (1.7%) and OEC (0.4%) are less prevalent. Individuals with OIC and OEC have a higher burden of illness with respect to symptom severity and prescription constipation medication use.

Gastrointestinal outcomes among older women with endometrial cancer.

OBJECTIVE: Treatment for endometrial cancer may contribute to bowel dysfunction and other gastrointestinal outcomes. We investigated the risk of several gastrointestinal diagnoses among older women with endometrial cancer and matched women without a history of cancer. METHODS: Women aged 66 years and older diagnosed with endometrial cancer during 2004-2017 (N = 44,386) and matched women without a known cancer history (N = 221,219) were identified in the SEER-Medicare linked data. An index date was defined as the endometrial cancer diagnosis date in that matched set. ICD-9 and -10 diagnosis codes were used to define gastrointestinal outcomes, including constipation, abdominal pain, IBS, fecal incontinence, bowel obstruction, ileus, radiation enteritis or proctitis, colonic stricture, and vascular insufficiency of the bowel in the Medicare claims. Hazard ratios (HRs) for incident gastrointestinal diagnoses were estimated using multivariable Cox proportional hazards regression models. RESULTS: Compared to women without cancer, women with endometrial cancer had an increased risk of gastrointestinal symptoms after the index date, including constipation (HR = 2.27; 95% CI: 2.22-2.32), abdominal pain (HR = 2.94; 95% CI: 2.89-2.99), and fecal incontinence (HR = 1.96; 95% CI: 1.83-2.10). The risk of other gastrointestinal diagnoses was also higher among women with endometrial cancer (e.g., bowel obstruction: HR = 5.72; 95% CI: 5.47-5.98; ileus: HR = 7.22; 95% CI: 6.89-7.57). These associations were also apparent in sensitivity analyses limited to 1+ and 5+ years after the index date. CONCLUSIONS: Older women with endometrial cancer experience an excess risk of gastrointestinal diagnoses that may persist long after cancer diagnosis. Surveillance for these conditions may be a critical part of survivorship care.

Picosulfato de sodio para alivio del estreñimiento / Sodium Picosulfate for Constipation Relief

INTRODUCCIÓN: La evidencia de cuidados paliativos es un planteamiento para mejorar la calidad de vida de los pacientes (adultos y niños) y sus familias, que afrontan problemas inherentes a una enfermedad potencialmente mortal. El de cuidados paliativos es un planteamiento para mejorar la calidad de vida de los pacientes (adultos y niños) y sus familias, que afrontan problemas inherentes a una enfermedad potencialmente mortal. Los cuidados paliativos permiten prevenir y aliviar el sufrimiento mediante la detección temprana, la evaluación correcta y el tratamiento del dolor y otros problemas. La atención paliativa previene y alivia el sufrimiento de todo orden, físico, psicológico, social o espiritual, que experimentan los adultos y niños que viven con problemas de salud que limitan la vida. Promueve la dignidad, la calidad de vida y la adaptación a las enfermedades progresivas, y utiliza para ello los mejores datos probatorios disponibles. Se calcula que en el mundo se requieren cuidados paliativos en el 40% al 60% de las defunciones 2. Los cuidados paliativos son necesarios para una amplia gama de enfermedades que limitan la vida. La mayoría de los adultos que los precisan tienen enfermedades crónicas, como enfermedades cardiovasculares (38,5%), cáncer (34%), enfermedades respiratorias crónicas (10,3%), sida (5,7%) y diabetes (4,6%). Muchas otras afecciones pueden requerir cuidados paliativos, incluidas la insuficiencia renal, la hepatopatía crónica, la artritis reumatoide, las enfermedades neurológicas, la demencia, las anomalías congénitas y la tuberculosis farmacorresistente. El dolor es uno de los síntomas más frecuentes y graves que sufren los pacientes que necesitan cuidados paliativos. Los analgésicos opioides son esenciales para tratar el dolor y otros síntomas físicos penosos comunes que se asocian con numerosas enfermedades progresivas en estado avanzado. Por ejemplo, el 80% de los pacientes con sida o cáncer y el 67% de los que padecen enfermedades cardiovasculares o enfermedad pulmonar obstructiva crónica experimentará dolor de moderado a intenso al final de la vida 3 En el 2011, el 83% de la población mundial vivía en países en los que el acceso a los analgésicos opioides era escaso o nulo. METODOLOGÍA: 1. Descripción del medicamento solicitado según FDA/AEMPS. 2. Informe Técnico: Revisión de la evidencia científica, recomendaciones de uso de las Agencias Reguladoras y Guías de Práctica Clínica de los medicamentos. 3. Costos del medicamento y disponibilidad. 4. Conclusiones. 5. Recomendaciones. RESULTADOS: Se han cotejado las fichas farmacológicas de Agencias Reguladoras como AEMPS/FDA, Con aprobación de la Food and Drug Administration (FDA) desde 1996 y de la European Medicines Agency (EMA) desde 1997. Además de verificar Expediente Electrónico de la DNM, para: PICOSULFATO DE SODIO. Además, se han encontrado publicaciones científicas que avalan el uso de este medicamento para enfermedad de Alzheimer de moderada a grave. CONCLUSIONES: De acuerdo a la investigación de información técnica y científica sobre el tema, se concluye lo siguiente: El ISSS cuenta con un Centro Especializado Integral de Atención Ambulatoria La Ceiba, la cual suministra Atención domiciliar y Cuidados paliativos. El dolor es uno de los síntomas más frecuentes y graves que sufren los pacientes que necesitan cuidados paliativos. Los analgésicos opioides son esenciales para tratar el dolor y otros síntomas físicos penosos comunes que se asocian con numerosas enfermedades progresivas en estado avanzado. Por ejemplo, el 80% de los pacientes con sida o cáncer y el 67% de los que padecen enfermedades cardiovasculares o enfermedad pulmonar obstructiva crónica experimentará dolor de moderado a intenso al final de la vida 18 En el 2011, el 83% de la población mundial vivía en países en los que el acceso a los analgésicos opioides era escaso o nulo. Según la OPS/OMS. el estreñimiento es altamente prevalente (50-95 %) en cuidados paliativos (CP). Alrededor del 90 % de los pacientes que reciben opioides fuertes y del 65% de los que no los reciben, requieren laxantes. A pesar de ser una importante causa de morbilidad, su importancia suele ser subestimada en el contexto de otros síntomas. Debido a las limitaciones que se encuentran en la definición de etiologías que encierra el término "estreñimiento", entre ellos: estreñimiento crónico idiopático, estreñimiento secundario por el uso de opioides, síndrome de intestino irritable con estreñimiento, entre otras, y cada una de estas etiologías representa una población diferente y por ende, un tratamiento específico. Además, entre las mismas etiologías de la enfermedad, existen diferencias de tratamiento entre pacientes según la edad y patologías subyacentes, por dar un ejemplo, el manejo del estreñimiento crónico idiopático es diferente en pacientes adultos que en población considerada de primera infancia. Varios medicamentos utilizados para el tratamiento del dolor y otros síntomas comunes en los cuidados paliativos, están incluidos en la Lista Modelo de la OMS de Medicamentos Esenciales para adultos y niños. Con estos medicamentos esenciales se puede aliviar adecuadamente la gran mayoría de los síntomas penosos para los pacientes. Los analgésicos opioides son esenciales para controlar eficazmente el dolor de moderado a intenso. Las directrices de la OMS del 2012 sobre manejo del dolor en niños recomiendan la analgesia fuerte con opioides, como esencial para el alivio del dolor de moderado a intenso en los niños. Desde la perspectiva del sistema de salud colombiano indican que tanto el picosulfato de sodio como la lactulosa, nominadas por el Ministerio de Salud y Protección Social no son estrategias costo efectivas frente al psyllium ya que este último tiene una mayor efectividad, pero, además, los costos estimados de utilizarlo son muchos menores. Al comparar la lactulosa (Código LOM 8020706), con las demás alternativas, se aprecia que es la menos efectiva, sin embargo, no es una diferencia sustancial, de hecho, es posible argumentar que ésta, junto con polietilenglicol, picosulfato de sodio, bisacodilo, prucaloprida y lubiprostone conforman un grupo con efectividades muy similares. Las diferencias que se aprecian están en el costo de las dos últimas, prucaloprida y lubiprostone tienen un costo que dobla al de las otras cuatro alternativas, bajo las condiciones actuales del mercado local (de Colombia). Con respecto a la información sobre efectividad y seguridad encontrada en las diferentes evaluaciones técnicas consultadas, sugieren que los medicamentos utilizados en estos casos, (mencionados arriba), son más efectivos frente al placebo, y que comparándolo uno a uno, estos no presentan diferencias de efectividad estadísticamente significativas.

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation.

INTRODUCTION: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.