Evaluation of the IncoStress device for urinary incontinence: a feasibility study and pilot randomised controlled trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the feasibility of recruitment to and outcomes from a pilot randomised study of the IncoStress device as an adjunct to conservative treatment for urinary incontinence. METHODS: Women with urinary incontinence were randomised on a 2:1 basis to usual care (control) or usual care plus use of the IncoStress device (intervention). Process outcomes (retention and compliance) were recorded plus symptom outcomes (IQOL and ICIQ-FLUTS questionnaires). A sample of participants took part in an interview to understand the frequency of use of the device and satisfaction. RESULTS: Eighty women (51 intervention, 29 control) were recruited. Follow-up responses were obtained from 34 intervention group (66.7%) and 17 (58.6%) control patients. Women used the device for a median 3 days a week (0-7), 18 out of 34 (53%) found it easy to use and 21 (61.8%) were satisfied with the device. Median IQOL score in the intervention group improved from a baseline of 42.4 (0-94) to 68.2 (5-98) at follow-up and in the control group from 45.5 (0-88) to 53.0 (0-94). Median ICIQ-FLUTS score in the intervention group improved from 14.5 (6-35) to 12.5 (4-26) and in the control group from 15.0 (5-35) to 14.0 (6-38). CONCLUSIONS: Recruitment and randomisation were feasible and robust. This study demonstrates that a large-scale RCT is feasible and the IncoStress has potential value.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.

BACKGROUND: Surgical site infection rates in the month following clean surgery vary from 0.6% (knee prosthesis) to 5% (limb amputation). Due to the large number of clean surgical procedures conducted annually the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Preoperative skin antisepsis using antiseptics is performed to reduce the risk of SSIs by removing soil and transient organisms from the skin where a surgical incision will be made. Antiseptics are thought to be toxic to bacteria and therefore aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however, it is unclear whether preoperative skin antisepsis actually reduces postoperative wound infection, and, if so, which antiseptic is most effective. OBJECTIVES: To determine whether preoperative skin antisepsis immediately prior to surgical incision for clean surgery prevents SSI and to determine the comparative effectiveness of alternative antiseptics. SEARCH METHODS: For this third update we searched just the Cochrane Wounds Group Specialised Register (searched 27 January 2015); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 12). SELECTION CRITERIA: Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There was no restriction on the inclusion of reports based on language of publication, date or publication status. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of risk of bias were undertaken independently by two review authors. MAIN RESULTS: There were no new studies added to the review in the third updateThirteen studies were included in this review (2,623 participants). These evaluated several different types of skin antiseptics - leading to 11 different comparisons being made. Although the antiseptics evaluated differed between studies, all trials involved some form of iodine. Iodine in alcohol was compared to alcohol alone in one trial; one trial compared povidone iodine paint (solution type not reported) with soap and alcohol. Six studies compared different types of iodine-containing products with each other and five compared iodine-containing products with chlorhexidine-containing products.There was evidence from one study suggesting that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits led to a reduced risk of SSI compared with an alcohol based povidone iodine solution: RR 0.47 (95% CI 0.27 to 0.82). However, it is important to note that the trial does not report important details regarding the interventions (such as the concentration of povidone iodine paint used) and trial conduct, such that risk of bias was unclear.There were no other statistically significant differences in SSI rates in the other comparisons of skin antisepsis. Overall the risk of bias in included studies was unclear.A mixed treatment comparison meta-analysis was conducted and this suggested that alcohol-containing products had the highest probability of being effective - however, again the quality of this evidence was low. AUTHORS' CONCLUSIONS: A comprehensive review of current evidence found some evidence that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of SSIs following clean surgery than alcohol-based povidone iodine paint. However this single study was poorly reported. Practitioners may therefore elect to consider other characteristics such as costs and potential side effects when choosing between alternatives.The design of future trials should be driven by the questions of high priority to decision makers. It may be that investment in at least one large trial (in terms of participants) is warranted in order to add definitive and hopefully conclusive data to the current evidence base. Ideally any future trial would evaluate the iodine-containing and chlorhexidine-containing solutions relevant to current practice as well as the type of solution used (alcohol vs. aqueous).

Disposable surgical face masks for preventing surgical wound infection in clean surgery.

BACKGROUND: Surgical face masks were originally developed to contain and filter droplets containing microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound, e.g. by incorrect wear or by leaking air from the side of the mask due to poor string tension. OBJECTIVES: To determine whether disposable surgical face masks worn by the surgical team during clean surgery prevent postoperative surgical wound infection. SEARCH METHODS: We searched The Cochrane Wounds Group Specialised Register on 23 October 2013; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask. DATA COLLECTION AND ANALYSIS: Two review authors extracted data independently. MAIN RESULTS: Three trials were included, involving a total of 2113 participants. There was no statistically significant difference in infection rates between the masked and unmasked group in any of the trials. AUTHORS' CONCLUSIONS: From the limited results it is unclear whether the wearing of surgical face masks by members of the surgical team has any impact on surgical wound infection rates for patients undergoing clean surgery.

Mechanical devices for urinary incontinence in women.

BACKGROUND: Incontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management, particularly when a woman does not want surgery or when she is considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment. OBJECTIVES: To determine whether mechanical devices are useful in the management of adult female urinary incontinence. SEARCH METHODS: For this second update we searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 21 August 2014), EMBASE (January 1947 to 2014 Week 34), CINAHL (January 1982 to 25 August 2014), and the reference lists of relevant articles. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined by symptom, sign or urodynamic diagnosis. DATA COLLECTION AND ANALYSIS: The reviewers assessed the identified studies for eligibility and risk of bias and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 5.3). MAIN RESULTS: One new trial was identified and included in this update bringing the total to eight trials involving 787 women. Three small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Four trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. One trial compared three groups: a mechanical device alone, behavioural therapy (pelvic floor muscle training) alone and behavioural therapy combined with a mechanical device. While at three months there were more withdrawals from the device-only group, at 12 months differences between the groups were not sustained on any measure. AUTHORS' CONCLUSIONS: The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and large well-conducted trials are required for clarification. There was also insufficient evidence in favour of one device over another and little evidence to compare mechanical devices with other forms of treatment.

Pressure-relieving interventions for treating diabetic foot ulcers.

BACKGROUND: Diabetes-related foot ulceration is a major contributor to morbidity in diabetes. Diabetic foot ulcers are partly a consequence of abnormal foot pressures and pressure relief is a widely used treatment for healing diabetes-related plantar foot ulcers, but the most effective method for healing is unclear. OBJECTIVES: To determine the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. SEARCH METHODS: For this update we searched the Cochrane Wounds Group Specialised Register (searched 2 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to October Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, October 31, 2012); Ovid EMBASE (1980 to 2012 Week 43); and EBSCO CINAHL (1982 to 1 November 2012). There were no restrictions based on language or publication status. SELECTION CRITERIA: Randomised controlled trials evaluating the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS: Data from eligible trials were extracted, and summarised using a data extraction sheet, by two review authors independently. MAIN RESULTS: Fourteen trials (709 participants) met the inclusion criteria for the review. One study compared two different types of non-removable casts with no discernable difference between the groups. Seven studies (366 participants) compared non-removable casts with removable pressure-relieving devices. In five of those studies non-removable casts were associated with a statistically significant increase in the number of ulcers healed compared with the removable device (RR 1.17 95% CI 1.01 to 1.36: P value = 0.04).Two studies (98 participants) found that significantly more ulcers healed with non-removable casts than with dressings alone. Achilles tendon lengthening combined with a non-removable cast in one study resulted in significantly more healed ulcers at 7 months than non-removable cast alone (RR 2.23; 95% CI 1.32 to 3.76). More ulcers remained healed at two years in this group (RR 3.41; 95% CI 1.42 to 8.18).Other comparisons included surgical debridement of ulcers; felt fitted to the foot; felted foam dressings and none of these showed a statistically significant treatment effect in favour of the intervention. AUTHORS' CONCLUSIONS: Non-removable, pressure-relieving casts are more effective in healing diabetes related plantar foot ulcers than removable casts, or dressings alone. Non-removable devices, when combined with Achilles tendon lengthening were more successful in one forefoot ulcer study than the use of a non-removable cast alone.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure. OBJECTIVES: To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes. SEARCH METHODS: In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies. DATA COLLECTION AND ANALYSIS: Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate. MAIN RESULTS: One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis. AUTHORS' CONCLUSIONS: Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.

Antibiotic prophylaxis for short-term catheter bladder drainage in adults.

BACKGROUND: Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters. OBJECTIVES: To determine if certain antibiotic prophylaxes are better than others in terms of prevention of urinary tract infections, complications, quality of life and cost-effectiveness in short-term catheterisation in adults. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, and handsearching of journals and conference proceedings (searched 31st October 2012). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing antibiotic prophylaxis for short-term (up to and including 14 days) catheterisation in adults. DATA COLLECTION AND ANALYSIS: Data were independently extracted by all review authors and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systemtic Reviews of Interventions. Where data had not been fully reported, clarification was sought directly from the authors of the trial. MAIN RESULTS: Six parallel-group randomised controlled trials with 789 participants met the inclusion criteria. All six trials compared antibiotic prophylaxis versus no prophylaxis. Studies presented a low to unclear risk of bias with similar interventions and measured outcomes.The primary outcome of bacteriuria was less common in the prophylaxis group amongst surgical patients with asymptomatic bacteriuria (I(2) = 0; risk ratio (RR) 0.20; 95% confidence interval (CI) 0.13 to 0.31) . Two non-surgical studies could not be combined in a meta-analysis due to heterogeneity and only one showed significantly fewer cases of bacteriuria (RR 0.19; 95% CI 0.09 to 0.37).Two trials of surgical patients with asymptomatic bacteriuria only (255 participants) compared one type of antibiotic prophylaxis with another and neither study showed a significant difference in cases of bacteriuria.One study (78 participants) compared antibiotic prophylaxis in patients at catheterisation only versus antibiotic prophylaxis throughout catheterisation period with asymptomatic bacteriuria. Antibiotics at catheterisation only, resulted in significantly fewer cases of bacteriuria than giving prophylaxis throughout the catheterisation period (RR 0.29 95% CI 0.09 to 0.91).Secondary data of pyuria were provided by two surgical studies (255 participants). When studies were pooled, pyuria occurred in significantly fewer cases in the prophylactic antibiotic group (RR 0.23, 95% CI 0.13 to 0.42). The number of gram-negative isolates in patients' urine just before catheter removal in one study (RR 0.05, 95% CI 0.00 to 0.79) and six weeks after hospital discharge (RR 0.36, 95% CI 0.23 to 0.56) were significantly lower. There were no events in the treatment group before catheter removal. When pooled data from two studies showed significantly reduced febrile morbidity in those receiving antibiotic prophylaxis (RR 0.53 95% CI 0.31 to 0.89).Although all studies assessed micro-organisms isolated from the urine specimens the data were too heterogenous to pool in a meta-analysis and have been provided in a narrative form. Further secondary data such as economic analysis, length of stay and quality of life were not covered in detail. AUTHORS' CONCLUSIONS: The limited evidence indicated that receiving prophylactic antibiotics reduced the rate of bacteriuria and other signs of infection, such as pyuria, febrile morbidity and gram-negative isolates in patients' urine, in surgical patients who undergo bladder drainage for at least 24 hours postoperatively. There was also limited evidence that prophylactic antibiotics reduced bacteriuria in non-surgical patients.

Cyanoacrylate microbial sealants for skin preparation prior to surgery.

BACKGROUND: Surgical site infections (i.e. incisions that become infected) are a continuing concern in health care. Microbial sealant is a liquid that can be applied to the skin immediately before surgery and is thought to help reduce the incidence of surgical site infections (SSIs) by sealing in the skin flora, thus preventing contamination and infection of the surgical site. OBJECTIVES: To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on rates of SSI in people undergoing clean surgery. SEARCH METHODS: For this first update we searched the following electronic databases in July 2013: the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid MEDLINE - In-Process & Other Non-Indexed Citations, Ovid EMBASE and EBSCO CINAHL. SELECTION CRITERIA: Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery (i.e. surgery that does not involve the breathing system, gut, genital or urinary tract or any part of the body with an existing infection) in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant. DATA COLLECTION AND ANALYSIS: All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trials. MAIN RESULTS: Three trials (524 participants undergoing clean surgery) met the inclusion criteria. The trials all compared cyanoacrylate microbial sealant with no sealant, and, when pooled, we found there were fewer SSIs with the use of microbial sealant (10/261 participants) than with the control comparison (29/274 participants). The difference between the two groups was statistically significant (risk ratio (RR) 0.36, 95% CI 0.18 to 0.72) but given the number of participants and quality of the studies, they should be treated with caution. There were some adverse events in one study, but these were not judged to be a result of the use of microbial sealant. AUTHORS' CONCLUSIONS: In this first update there is still insufficient evidence available to determine whether the use of microbial sealants reduces the risk of surgical site infection or not. Further rigorous, adequately-powered RCTs are required to investigate this properly.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.

BACKGROUND: Surgical site infection rates in the month following clean surgery vary from 0.6% (knee prosthesis) to 5% (limb amputation). Due to the large number of clean surgical procedures conducted annually the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Preoperative skin antisepsis using antiseptics is performed to reduce the risk of SSIs by removing soil and transient organisms from the skin where a surgical incision will be made. Antiseptics are thought to be toxic to bacteria and therefore aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however, it is unclear whether preoperative skin antisepsis actually reduces postoperative wound infection, and, if so, which antiseptic is most effective. OBJECTIVES: To determine whether preoperative skin antisepsis immediately prior to surgical incision for clean surgery prevents SSI and to determine the comparative effectiveness of alternative antiseptics. SEARCH METHODS: For this second update we searched the The Cochrane Wounds Group Specialised Register (searched 7 August 2012), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE  (1950 to July Week 4 2012), Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 06, 2012), Ovid EMBASE (1980 to 2012 Week 31), EBSCO CINAHL (2007 to 3 August 2012). SELECTION CRITERIA: Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There was no restriction on the inclusion of reports based on language of publication, date or publication status. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of risk of bias were undertaken independently by two review authors. MAIN RESULTS: Thirteen studies were included in this review (2,623 participants). These evaluated several different types of skin antiseptics - leading to 11 different comparisons being made. Although the antiseptics evaluated differed between studies, all trials involved some form of iodine. Iodine in alcohol was compared to alcohol alone in one trial; one trial compared povidone iodine paint (solution type not reported) with soap and alcohol. Six studies compared different types of iodine-containing products with each other and five compared iodine-containing products with chlorhexidine-containing products.There was evidence from one study suggesting that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits led to a reduced risk of SSI compared with an alcohol based povidone iodine solution: RR 0.47 (95% CI 0.27 to 0.82). However, it is important to note that the trial does not report important details regarding the interventions (such as the concentration of povidone iodine paint used) and trial conduct, such that risk of bias was unclear.There were no other statistically significant differences in SSI rates in the other comparisons of skin antisepsis. Overall the risk of bias in included studies was unclear.A mixed treatment comparison meta-analysis was conducted and this suggested that alcohol-containing products had the highest probability of being effective - however, again the quality of this evidence was low. AUTHORS' CONCLUSIONS: A comprehensive review of current evidence found some evidence that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of SSIs following clean surgery than alcohol-based povidone iodine paint. However this single study was poorly reported. Practitioners may therefore elect to consider other characteristics such as costs and potential side effects when choosing between alternatives.The design of future trials should be driven by the questions of high priority to decision makers. It may be that investment in at least one large trial (in terms of participants) is warranted in order to add definitive and hopefully conclusive data to the current evidence base. Ideally any future trial would evaluate the iodine-containing and chlorhexidine-containing solutions relevant to current practice as well as the type of solution used (alcohol vs. aqueous).

Follow-up for improving psychological well being for women after a miscarriage.

BACKGROUND: Miscarriage is the premature expulsion of an embryo or fetus from the uterus up to 23 weeks of pregnancy and weighing up to 500 grams. International studies using diagnostic tools have identified that some women suffer from anxiety, depression and grief after miscarriage. Psychological follow-up might detect those women who are at risk of psychological complications following miscarriage. This review is necessary as the evidence is equivocal on the benefits of psychological follow-up after miscarriage. OBJECTIVES: Whether follow-up affects the psychological well being of women following miscarriage. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011), reference lists of all retrieved papers and contacted professional and lay organisations to obtain any ongoing trials or unpublished data. SELECTION CRITERIA: Randomised controlled trials only. DATA COLLECTION AND ANALYSIS: All potential trials for eligibility according to the criteria specified in the protocol by screening the titles and abstracts, retrieving full reports of potentially relevant trials for assessment. All review authors extracted data and checked for accuracy. No studies were published in duplicate. When data were missing and only the abstract was available, we attempted to contact the trial authors. We resolved any disagreement through discussion. MAIN RESULTS: Six studies involving 1001 women were included. Three trials compared one counselling session with no counselling. There was no significant difference in psychological well being including anxiety, grief, depression avoidance and self-blame. One trial compared three one-hour counselling sessions with no counselling at four and 12 months. Some subscales showed statistical significance in favour of counselling and some in favour of no counselling. The results for two trials were given in narrative form as data were unavailable for meta-analyses. One trial compared multiple interventions. The other trial compared two counselling sessions with no counselling. Neither study favoured counselling. AUTHORS' CONCLUSIONS: Evidence is insufficient to demonstrate that psychological support such as counselling is effective post-miscarriage. Further trials should be good quality, adequately-powered using standardised interventions and outcome measures at specific time points. The economic implications and women's satisfaction with psychological follow-up should also be explored in any future study.

Graduate foundation scheme with a focus on dignity and older adults.

The care experiences of older people in Wales and the rest of the UK have risen to the top of the political agenda recently, and it is the role of nurse managers to find ways to meet the dignity agenda. A review by the Older People's Commissioner for Wales (Marks 2011) recommends that 'better knowledge of the needs of older people with dementia is needed, together with improved communication, training, support and standards of care'. In an effort to meet this recommendation, one healthcare organisation, Cwm Taf Health Board, has developed a graduate foundation programme that focuses on the dignity of older patients in various hospital settings. This article describes the development and implementation of the programme.

Mechanical devices for urinary incontinence in women.

BACKGROUND: ncontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management, particularly when a woman does not want surgery or when she is considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment. OBJECTIVES: To determine the effects of mechanical devices in the management of adult female urinary incontinence. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 23 June 2010), EMBASE (January 1947 to 2010 Week 24), CINAHL (January 1982 to 11 June 2010) and the reference lists of relevant articles. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined by symptom, sign or urodynamic diagnosis. DATA COLLECTION AND ANALYSIS: The reviewers assessed the identified studies for eligibility and risk of bias and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 5.0.25). MAIN RESULTS: One new trial was identified and included in this update bringing the total to seven trials involving 732 women. Two small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Four trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. One new trial compared three groups: a mechanical device alone, behavioural therapy (pelvic floor muscle training) alone and behavioural therapy combined with a mechanical device. While at three months, there were more withdrawals from the device-only group, at 12 months group differences between the groups were not sustained on any measure. AUTHORS' CONCLUSIONS: The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and large well-conducted trials are required for clarification. There was also insufficient evidence in favour of one device over another and little evidence to compare mechanical devices with other forms of treatment.

Self-preservation in abortion care: a grounded theory study.

AIM: To seek an explanation as to why nurses concede and conceal their judgements towards women having an abortion. BACKGROUND: Recent advances in abortion techniques and pharmacology have resulted in a greater proportion of medical abortions occurring at a lower gestation than previously. As this technique demands more of nurses, it becomes important to ask whether they are equipped to deal with this greater involvement. DESIGN: A grounded theory approach using a recognised framework was used. Theoretical sampling was used in this study to increase the depth of focus from a previous study of nurses who were found to concede and conceal their judgement in abortion care. FINDINGS: Several important aspects of abortion care were elucidated as to why nurses concealed and conceded their judgements. Lower gestation of abortions was central in determining greater involvement of nurses in the abortion process. It was found that some nurses treated women the same and some treated women differently, but all strived for equitable care. Self-preservation in the form of 'switching off' or 'getting on with it' was employed by nurses when they encountered the foetus or women who were blasé. Self-preservation was found to be a key phenomenon and a major reason why nurses conceded and then concealed their judgement. CONCLUSIONS: In rapidly advancing abortion care, there needs to be positive ways of ensuring self-preservation in nurses without compromising care. RELEVANCE TO CLINICAL PRACTICE: Abortion care demands specific skills of nurses, and this is likely to increase in the near future. Self-preservation needs to be embedded into nurses' professional development by the use of positive strategies such as guided reflection in providing a productive woman-centred service.

Stigma in abortion care: application to a grounded theory study.

A recent research study found that being more directly involved in medical abortion places greater demands on the nurses. The demands required by nurses working in abortion care may be increased by the stigma attached to such an antisocial action. This paper presents an application of stigma theory, as espoused by Goffman, based on a qualitative research study on abortion. It is argued that women attending for abortion are stigmatised and nurses, although 'wise', have an affiliate stigma through their close association with the procedure. It is proposed that the situation can be ameliorated by addressing stigma at policy, local and personal levels. Examples from other areas of practice are outlined for possible application to practice.

Cyanoacrylate microbial sealants for skin preparation prior to surgery.

BACKGROUND: Surgical site infections are a continuing concern in health care. Microbial sealant is a liquid applied to the skin immediately before surgery. It is thought to contribute to reducing surgical site infections by sealing in the skin flora to prevent contamination and infection of the surgical site. OBJECTIVES: To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on the rates of surgical site infection in people undergoing clean surgery. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), Ovid MEDLINE (1950 to April Week 3 2010), Ovid MEDLINE - In-Process & Other Non-Indexed Citations (searched 10 May 2010), Ovid EMBASE (1980 to 2010 Week 18) and EBSCO CINAHL (1982 to 10 May 2010). We searched bibliographies and contacted manufacturers of microbial sealants for unpublished studies. There were no restrictions based on language, date or publication status. SELECTION CRITERIA: Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant. DATA COLLECTION AND ANALYSIS: All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trial. MAIN RESULTS: One small trial (177 participants undergoing hernia repair) met the inclusion criteria. There was no statistically significant difference in the rates of surgical site infection (three patients in the control group developed a surgical site infection compared with none in the intervention group; risk ratio (RR) 0.17, 95% CI 0.01 to 3.19, P = 0.23). AUTHORS' CONCLUSIONS: There is currently insufficient evidence as to whether the use of microbial sealants reduces the risk of surgical site infection in people undergoing clean surgery and further rigorous RCTs are required.

Service provision for women undergoing termination of pregnancy: progress in Wales, UK.

BACKGROUND: This audit established a recent picture of termination of pregnancy services in Wales, UK using the Royal College of Obstetricians and Gynaecologists' Guidelines as a baseline. The context of abortion is rapidly changing and services need to be adaptable to meet women's needs. METHODS: A questionnaire survey was sent to all National Health Service (NHS) Trusts in Wales; 10 out of 13 responded. RESULTS: In the nine Trusts performing abortions in Wales, medical abortions accounted for 57% and surgical abortions for 43%. Doctors in training were involved in six Trusts. All but one Trust complied with referral times. Five Trusts provided a dedicated clinic. Written information provided prior to abortion varied in accessibility and quality. Choice of abortion within gestation bands was limited in some Trusts with some only providing medical termination. Essential abortion aftercare was performed by Trusts, whereas follow-up and counselling were less comprehensive. DISCUSSION: Trusts are willing to adapt to new methods of working with an increasing number of medical terminations, although this advantage was offset by a lack of choice of abortion methods offered by some Trusts. Doctors in training should be offered exposure to abortion procedures in all Trusts as this has been shown elsewhere to improve attitudes. Providing dedicated abortion clinics, quality written information and comprehensive abortion aftercare should improve compliance with the guidelines. CONCLUSION: Overall, in Wales there is compliance with national guidelines, although for a number of the guideline recommendations there remains room for improvement.

A systematic review of prophylactic antimicrobials in PEG placement.

AIM: To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies. BACKGROUND: Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement. DESIGN: Systematic review. METHODS: We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. RESULTS: Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT. CONCLUSIONS: Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection. RELEVANCE TO CLINICAL PRACTICE: The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.

Nurses in abortion care: identifying and managing stress.

The psychological impact of abortion on the women undergoing the procedure is well researched, but little is known about the potential psychological impact on nurses working in abortion care. The proportion of medical abortions in the UK is rising compared to surgical abortions. A recent research study found that being more directly involved in the procedure places more emotional demands on the nurses. This emotional labour required by nurses working in abortion care may increase their stress levels. This paper examines the potential increase in stress in nurses caused by medical abortions. A model of stress comprising stressors, moderators and stress outcomes was used as a framework for this examination. Research on abortion and mental health nursing was applied to managing stress in abortion care; this included coping mechanisms, prevention and intervention strategies. This showed that stress, burnout and coping are important issues in abortion care. On this basis, recommendations for practice have been formulated to inform practice for nurses and managers in abortion care.

Termination of pregnancy: a review of psychological effects on women.

Termination of pregnancy may have psychological consequences that are greater than its physical impact. Following a literature search and appraisal, this article explores some of the main themes arising from studies on the psychological impact. The results demonstrate that negative psychological effects are more likely in certain high-risk women. A table of indicators has been developed which could assist nurses in recognising whether a woman is at risk of negative psychological effects after termination.

Exchanging information: patients' views on health care.

Patient support systems in Wales, including information services, are delivered by front line staff rather than dedicated support services teams. This article discusses an evaluation of patients' healthcare information experiences in primary and secondary care settings, and argues that front line staff are improving care by encouraging a communicative partnership with patients.