Conservative, physical and surgical interventions for managing faecal incontinence and constipation in adults with central neurological diseases.

BACKGROUND: People with central neurological disease or injury have a much higher risk of both faecal incontinence (FI) and constipation than the general population. There is often a fine line between the two symptoms, with management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. This is an update of a Cochrane Review first published in 2001 and subsequently updated in 2003, 2006 and 2014. OBJECTIVES: To assess the effects of conservative, physical and surgical interventions for managing FI and constipation in people with a neurological disease or injury affecting the central nervous system. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (searched 27 March 2023), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles. SELECTION CRITERIA: We included randomised, quasi-randomised (where allocation is not strictly random), cross-over and cluster-randomised trials evaluating any type of conservative, physical or surgical intervention against placebo, usual care or no intervention for the management of FI and constipation in people with central neurological disease or injury. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the risk of bias in eligible trials using Cochrane's 'Risk of bias' tool and independently extracted data from the included trials using a range of prespecified outcome measures. We produced summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 25 studies with 1598 participants. The studies were generally at high risk of bias due to lack of blinding of participants and personnel to the intervention. Half of the included studies were also at high risk of bias in terms of selective reporting. Outcomes were often reported heterogeneously across studies, making it difficult to pool data. We did not find enough evidence to be able to analyse the effects of interventions on individual central neurological diseases. Additionally, very few studies reported on the primary outcomes of self-reported improvement in FI or constipation, or Neurogenic Bowel Dysfunction Score. Conservative interventions compared with usual care, no active treatment or placebo Thirteen studies assessed this comparison. The interventions included assessment-based nursing, holistic nursing, probiotics, psyllium, faecal microbiota transplantation, and a stepwise protocol of increasingly invasive evacuation methods. Conservative interventions may result in a large improvement in faecal incontinence (standardised mean difference (SMD) -1.85, 95% confidence interval (CI) -3.47 to -0.23; 3 studies; n = 410; low-certainty evidence). We interpreted SMD ≥ 0.80 as a large effect. It was not possible to pool all data from studies that assessed improvement in constipation, but the evidence suggested that conservative interventions may improve constipation symptoms (data not pooled; 8 studies; n = 612; low-certainty evidence). Conservative interventions may lead to a reduction in mean time taken on bowel care (data not pooled; 5 studies; n = 526; low-certainty evidence). The evidence is uncertain about the effects of conservative interventions on condition-specific quality of life and adverse events. Neurogenic Bowel Dysfunction Score was not reported. Physical therapy compared with usual care, no active treatment or placebo Twelve studies assessed this comparison. The interventions included massage therapy, standing, osteopathic manipulative treatment, electrical stimulation, transanal irrigation, and conventional physical therapy with visceral mobilisation. Physical therapies may make little to no difference to self-reported faecal continence assessed using the St Mark's Faecal Incontinence Score, where the minimally important difference is five, or the Cleveland Constipation Score (MD -2.60, 95% CI -4.91 to -0.29; 3 studies; n = 155; low-certainty evidence). Physical therapies may result in a moderate improvement in constipation symptoms (SMD -0.62, 95% CI -1.10 to -0.14; 9 studies; n = 431; low-certainty evidence). We interpreted SMD ≥ 0.5 as a moderate effect. However, physical therapies may make little to no difference in Neurogenic Bowel Dysfunction Score as the minimally important difference for this tool is 3 (MD -1.94, 95% CI -3.36 to -0.51; 7 studies; n = 358; low-certainty evidence). We are very uncertain about the effects of physical therapies on the time spent on bowel care, condition-specific quality of life and adverse effects (all very low-certainty evidence). Surgical interventions compared with usual care, no active treatment or placebo No studies were found for surgical interventions that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: There remains little research on this common and, for patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other. Understanding whether there is a clinically-meaningful difference from the results of available trials is largely hampered by the lack of uniform outcome measures. This is due to an absence of core outcome sets, and development of these needs to be a research priority to allow studies to be compared directly. Some studies used validated constipation, incontinence or condition-specific measures; however, others used unvalidated analogue scales to report effectiveness. Some studies did not use any patient-reported outcomes and focused on physiological outcome measures, which is of relatively limited significance in terms of clinical implementation. There was evidence in favour of some conservative interventions, but these findings need to be confirmed by larger, well-designed controlled trials, which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

Group-based pelvic floor muscle training for pregnant women: A randomized controlled feasibility study.

AIM: This study aims to test the feasibility and acceptability of a group-based pelvic floor muscle training for pregnant women in China and facilitate women's adherence to the pelvic floor muscle training programme. BACKGROUND: Urinary incontinence is a prevalent health problem in women worldwide, especially in pregnant women. Supervised pelvic floor muscle training is recommended as the first-line conservative treatment for urinary incontinence. However, the implementation and effectiveness of pelvic floor muscle training are limited by insufficient human resources and low adherence. Group-based interventions may improve people's adherence to interventions by facilitating peer support. However, it has been investigated in a limited number of maternity studies. DESIGN: Feasibility testing randomized controlled trial, accompanied by a mixed methods process evaluation. METHODS: This study was guided by the Medical Research Council framework for complex interventions and the Behaviour Change Wheel guide to developing interventions. A three-phase, mixed-methods design was used in this study. This study reported the feasibility of the group-based pelvic floor muscle training programme. Semi-structured reviews were conducted following the intervention to explore the acceptability of the programme. RESULTS: The study included 48 pregnant women with a recruitment rate of 52.17%. The adherence rate to the training programme was 66.67%. The intervention was positively valued, in particular the support promoting participants' adherence, but additional changes need to be made to the programme for a future trial. CONCLUSIONS: Group-based pelvic floor muscle training programme provides a possible way of delivering pelvic floor muscle training with limited health professionals in China. The study showed promising results concerning the acceptability and feasibility of the intervention, which were well perceived by both pregnant women and the midwife. IMPLICATIONS FOR PATIENT CARE: Group-based pelvic floor muscle training may have the potential of reducing the prevalence of urinary incontinence in pregnant women with insufficient healthcare professionals. IMPACT: This study assessed the feasibility of delivering group-based pelvic floor muscle training in pregnant women in China. The group-based pelvic floor muscle training is acceptable to both pregnant women and the midwife, but integrating online and face-to-face sessions need to be considered. The findings of this study provided evidence for delivering group-based pelvic floor muscle training to pregnant women in China. REPORTING METHOD: The study has adhered to CONSORT guidelines (Table S1) and TIDier checklist (Table S2). PATIENT AND PUBLIC CONTRIBUTION: The patient and public have been invited as stakeholders during the development of the intervention. They worked with healthcare professionals to co-design the group-based pelvic floor muscle training programme. REGISTRATION: The trial was registered on ClinicalTrials.gov (NCT05242809) under the title 'Development and Feasibility Testing of a Group-based PFMT Programme for Antenatal Women in Nanjing City in China'.

Effectiveness of interventions to enhance shared decision-making in wound care: A systematic review.

AIMS: To explore the effectiveness of interventions to enhance patient participation in shared decision-making in wound care and tissue viability. BACKGROUND: Caring for people living with a wound is complex due to interaction between wound healing, symptoms, psychological wellbeing and treatment effectiveness. To respond to this complexity, there has been recent emphasis on the importance of delivering patient centred wound care and shared decision-making to personalise health care. However, little is known about the effectiveness of existing interventions to support shared decision-making in wound care. DESIGN: Systematic review of interventional studies to enhance shared decision-making in wound care or tissue viability. This was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020. METHODS: Interventional primary research studies published in English up to January 2023 were included. Screening, data extraction and quality appraisal were undertaken independently by two authors. DATA SOURCES: Medline, EMBASE, Cochrane Central Register of Controlled Trails (trials database), CINAHL, British Nursing Index (BNI), WorldCat (thesis database), Scopus and registries of ongoing studies (ISRCTN registry and clinicaltrials.gov). RESULTS: 1063 abstracts were screened, and eight full-text studies included. Findings indicate, interventions to support shared decision-making are positively received. Goal or need setting components may assist knowledge transfer between patient and clinician, and could lower short term decisional conflict. However, generally findings within this study had very low certainty due to the inconsistencies in outcomes reported, and the variation and complexity of single and multiple interventions used. CONCLUSIONS: Future research on shared decision-making interventions in wound care should include the involvement of stakeholders and programme theory to underpin the interventions developed to consider the complexity of interventions. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Patients setting out their needs or goals and exploring patient questions are important and should be considered in clinical care. REGISTRATION: The review protocol was prospectively registered (PROSPERO database: CRD42023389820). NO PATIENT OR PUBLIC CONTRIBUTION: Not applicable as this is a systematic review.

What influences the inclusion of skin tone diversity when teaching skin assessment? Findings from a survey.

BACKGROUND: Understanding the variances in visual skin changes across all skin tones is important in clinical care. However, the experiences of those teaching skin assessment to pre- and post-registrant nurses are unknown. AIMS: To determine the barriers and facilitators experienced in teaching skin assessment across a range of skin tones to pre- and post-registrant nurses. METHODS: A cross-sectional, mixed-methods online survey was undertaken throughout February and March 2023 based on the Theoretical Domains Framework of behaviour change. FINDINGS: In this self-selecting sample, most participants were aware of why it was important to include all skin tones when teaching skin assessment and were professionally motivated to include this in their practice. However, resources and support are needed to overcome an unconscious bias in teaching skin tone diversity, resulting in a lack of availability of good quality photographs and educator confidence in their own skills. Educators not considering skin tone when selecting patient cases and relying on people with dark skin tones to highlight where practice is not inclusive may also lead to insufficient exposure for students. CONCLUSION: There is some awareness of the importance of including diverse skin tones in teaching, but further education and resources are needed.

"It is like a pet in a way": The self-management experiences of people with cystic fibrosis diabetes.

BACKGROUND: Cystic fibrosis diabetes (CFD) is a very common co-morbidity affecting the lives of people with cystic fibrosis. Surprisingly, minimal research has been undertaken to understand the experiences of people with CFD and how they self-mange this condition. METHODS: Using interpretative phenomenological analysis, the present study examined the self-management experiences of people with CFD. In-depth semi-structure interviews were conducted with eight people who had CFD. RESULTS: The following three superordinate themes were identified: forming a relationship with CFD, balancing the CFD self-management triad, and the unmet need for information and support. CONCLUSIONS: The findings suggest that the management of CFD is challenging and, although people with CFD experience many adaptation and management processes similar to people with type 1 diabetes, they struggle with the additional complexity of balancing CF and CFD. The provision of appropriate education, support and person-centred care needs to be addressed.

The effectiveness of group-based pelvic floor muscle training in preventing and treating urinary incontinence for antenatal and postnatal women: a systematic review.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is prevalent in antenatal and postnatal women. Pelvic floor muscle training (PFMT) is the first-line treatment for UI. Group-based PFMT provides a way for professionals to deliver this intervention to more women who need to prevent and/or treat UI. This review aims to (1) assess the effectiveness of group-based PFMT in preventing and treating UI in antenatal and postnatal women and (2) explore the characteristics of group-based intervention and factors which had an impact on the success of group-based PFMT. METHODS: Randomized controlled trials (RCTs) were included in this review. A comprehensive search was conducted in PubMed, Embase, Medline, PsycINFO, Maternity and Infant Care Database, CINAHL, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Database and Wanfang Database. The overall quality was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RCTs which included pregnant and/or postnatal women with or without UI investigating the effectiveness of group-based PFMT were included. RESULTS: Five RCTs were included in this review. The overall quality of the results of the included studies was low. Delivering group-based PFMT during pregnancy significantly reduced the prevalence of UI in both the pregnant period [risk ratio (RR) = 0.67, 95% confidence interval (CI) 0.57 to 0.80, P < 0.00001] and the postnatal period [RR = 0.66, 95% CI 0.52 to 0.84, P = 0.0008]. Only one RCT delivered group-based PFMT during the postnatal period. CONCLUSION: Evidence of weak quality supports the effectiveness of undertaking group-based PFMT in pregnancy to prevent UI during pregnancy and the postnatal period. No evidence showed the effectiveness of undertaking group-based PFMT in the postnatal period.

Moisture-associated skin damage: use of a skin protectant containing manuka honey.

The skin is the largest organ in the body, providing an effective barrier against excessive fluid loss and invasion from bacteria, but the barrier function of the skin can be lost when it is damaged by prolonged contact with moisture. Moisture-associated skin damage can be caused by prolonged exposure to perspiration, urine or faeces, wound exudate or stomal output. Prevention and treatment of moisture-associated skin damage involves application of skin protectants, but there is a wide range of these products available to nursing staff, and clinical decision making is hampered by a lack of robust comparative evidence. Medihoney® Barrier Cream may be used for a number of indications related to moisture-associated skin damage, including incontinence-associated dermatitis. The use of Medihoney Barrier Cream has been shown to lower pruritis complaints associated with intertrigo, and promotes patient comfort.

Experience of Nurses Caring for Patients With Neurogenic Bowel Dysfunction: A Qualitative Study.

PURPOSE: The purpose of this study was to explore the experience and perceptions of nurses providing bowel care to patients after spinal cord injury. DESIGN: Qualitative study using thematic analysis of semistructured interviews. SUBJECTS AND SETTING: Eleven RNs who provided bowel care to patients following spinal cord injury and were deemed competent to do so by their employer were invited to participate. The study setting was a large, London NHS Trust providing acute hospital care to a population of around 1 million people. METHODS: Semistructured interviews were digitally audio-recorded and transcribed verbatim. Analysis of data was undertaken using Braun and Clark's 6 stages of thematic analysis. RESULTS: Four main themes emerged: (1) unpleasantness of task; (2) perceived patient experience; (3) motivation and avoidance; and (4) barriers to care. There was stoic acceptance of the unpleasant nature of bowel care for the nurse, but unpleasantness for patients was not as readily acknowledged. Perceived patient experience ranged from descriptions of positive aspects of comfort and continence to negative aspects of embarrassment and discomfort. Nurses were motivated by the medical need for bowel care but often saw it as low priority due to the unpleasant nature and displayed avoidance tactics. The barriers concerned inadequate training, the taboo nature of bowel care, and potential sexual interpretations of care. CONCLUSION: Nurses described bowel care as unpleasant but accepted its physiologic need and importance. The standardization of bowel care training and increasing the numbers of nurses trained in bowel care may decrease stigma surrounding provision of care. Study findings suggest that male nurses' experience may differ from female nurses' experience, but this result requires further investigation.

'It is what it is': mothers' experiences of providing bladder and bowel care to their daughters living with life-limiting conditions.

BACKGROUND: Informal carers (carers) support palliative patients to live at home. Most palliative patients require bladder and bowel care (B&BC) at some point, but there is limited evidence about carers providing B&BC and how best to support them. AIM: To explore carers' experiences of providing B&BC to life-limited young adults. METHODS: Interpretative phenomenological analysis of five interviews with purposively selected carers. RESULTS: One overarching theme, 'It is what it is', and three superordinate themes ('Whatever my daughter needs', 'Mum knows best', and 'Coping with caring') emerged. While B&BC could be challenging at times, it was not a major concern. Instead it engendered closeness and opportunities for carers to provide better care than they felt professionals could. CONCLUSIONS: This study informs how professionals should understand the support carers offer. Professionals should ensure that carer/patient dyads who wish to manage B&BC are supported to do so, and that their support needs are regularly assessed.

Hand decontamination in clinical practice: a review of the evidence.

Hand decontamination is known to significantly reduce the spread of hospital-acquired infections but, despite a wealth of guidelines and education campaigns, evidence suggests that many healthcare workers are non-compliant with hand decontamination. The behaviours that prevent hand decontamination are complex. Studies look at attitudes towards dirt, disgust, self-protective hand washing and familiarity with patients. Self-protection behaviours manifest themselves in washing hands more often after certain tasks. Professional issues are also reported to have an impact on hand decontamination, mainly lack of time, heavy workloads, understaffing and frequency of admissions to the clinical area. Further research needs to be undertaken to include comparison between self-reported studies and observational studies, as it has been shown that healthcare workers may rationalise their behaviour and that self-reporting can be unreliable.

Interventions for preventing and treating incontinence-associated dermatitis in adults.

BACKGROUND: Incontinence-associated dermatitis (IAD) is one of the most common skin problems in adults who are incontinent for urine, stool, or both. In practice, products and procedures are the same for both prevention and treatment of IAD. OBJECTIVES: The objective of this review was to assess the effectiveness of various products and procedures to preventand treat incontinence-associated dermatitis in adults. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 September 2016). Additionally we searched other electronic databases: CENTRAL(2015, Issue 4), MEDLINE (January 1946 to May Week 3 2015), MEDLINE In-Process (inception to 26 May 2015), CINAHL(December 1981 to 28 May 2015), Web of Science (WoS; inception to 28 May 2015) and handsearched conference proceedings (to June 2015) and the reference lists of relevant articles, and contacted authors and experts in the field. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) and quasi-RCTs, performed in any healthcare setting, with included participants over 18 years of age, with or without IAD. We included trials comparing the (cost) effectiveness of topical skin care products such as skin cleansers, moisturisers, and skin protectants of different compositions and skin care procedures aiming to prevent and treat IAD. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full-texts, extracted data, and assessed the risk of bias of the included trials. MAIN RESULTS: We included 13 trials with 1295 participants in a qualitative synthesis. Participants were incontinent for urine, stool, or both, and were residents in a nursing home or were hospitalised.Eleven trials had a small sample size and short follow-up periods. .The overall risk of bias in the included studies was high. The data were not suitable for meta-analysis due to heterogeneity in participant population, skin care products, skin care procedures, outcomes, and measurement tools.Nine trials compared different topical skin care products, including a combination of products. Two trials tested a structured skin care procedure. One trial compared topical skin care products alongside frequencies of application. One trial compared frequencies of application of topical skin care products.We found evidence in two trials, being of low and moderate quality, that soap and water performed poorly in the prevention and treatment of IAD (primary outcomes of this review). The first trial indicated that the use of a skin cleanser might be more effective than the use of soap and water (risk ratio (RR) 0.39, 95% confidence interval (CI) 0.17 to 0.87; low quality evidence). The second trial indicated that a structured skin care procedure, being a washcloth with cleansing, moisturising, and protecting properties, might be more effective than soap and water (RR 0.31, 95% CI 0.12 to 0.79; moderate quality evidence). Findings from the other trials, all being of low to very low quality, suggest that applying a leave-on product (moisturiser, skin protectant, or a combination) might be more effective than not applying a leave-on product. No trial reported on the third primary outcome 'number of participants not satisfied with treatment' or on adverse effects. AUTHORS' CONCLUSIONS: Little evidence, of very low to moderate quality, exists on the effects of interventions for preventing and treating IAD in adults. Soap and water performed poorly in the prevention and treatment of IAD. Application of leave-on products (moisturisers, skin protectants, or a combination) and avoiding soap seems to be more effective than withholding these products. The performance of leave-on products depends on the combination of ingredients, the overall formulation and the usage (e.g. amount applied). High quality confirmatory trials using standardised, and comparable prevention and treatment regimens in different settings/regions are required. Furthermore, to increase the comparability of trial results, we recommend the development of a core outcome set, including validated measurement tools. The evidence in this review is current up to 28 September 2016.

Identifying disease-specific distress in patients with inflammatory bowel disease.

OBJECTIVES: Inflammatory bowel disease (IBD) imposes a significant burden on patients. The authors have noticed an underlying presence of distress, seemingly distinct from anxiety and depression, in qualitative data collected for previous studies. Disease-related distress has been explored in diabetes, but has not been addressed in IBD. The authors aimed to determine the presence of IBD distress to inform development of a scale for assessing the phenomenon. METHODS: This three-phase study used (1) a conceptual framework based on diabetes distress to conduct secondary analysis of qualitative data from four previous IBD studies (n=49 transcripts). Patient advisors confirmed the themes identified as causing distress, which guided (2) a focus group with people with IBD (n=8) and (3) items generated from phase 1 and 2 were subsequently used for a modified Delphi survey of IBD health professionals. RESULTS: Five IBD-distress themes were identified: emotional distress; healthcare-related distress; interpersonal/social distress; treatment-related distress; and symptom-related distress. DISCUSSION: Disease-specific distress in IBD was identified and is distinct from stress, anxiety and depression. Some causes of IBD distress overlap with diabetes distress, but existing diabetes-distress scales do not explain all the distress experienced by people with IBD and development of a new IBD-distress scale is warranted.

The Glasgow Coma Scale in adults: doing it right.

After 40 years, the Glasgow Coma Scale (GCS) is the resource of choice for assessing the level of consciousness in patients with neurological conditions. Clinicians' ability to monitor patients' conditions, identify deterioration and make clinical decisions depends on their ability to carry out GCS assessments, so it is vital that they understand it. This article explores how best to use the GCS in clinical practice and examines some of the factors that can affect the accuracy of assessments. The article also explains the difference between peripheral and central stimuli.

Pelvic floor muscle training for urinary incontinence postpartum.

The offering of pelvic floor muscle exercises to all women during their first pregnancy is recommended by National Institute for Health and Care Excellence (NICE) guidelines. Pelvic floor muscles suffer significant trauma throughout pregnancy and childbirth, which may sometimes lead to urinary incontinence postpartum. However, it is uncertain how effective pelvic floor muscle exercises are in treating this incontinence. Several trials have been analysed to try to understand this question. Issues such as when the exercises were undertaken, how often they were performed and in what circumstances they were carried out, have all been considered. While it is still uncertain whether they are effective in reducing urinary incontinence postpartum, as they are non-invasive and fairly simple to carry out, they are still the first-line management for urinary incontinence postpartum with other treatments being considered if this is ineffective.

Biofeedback for treatment of chronic idiopathic constipation in adults.

BACKGROUND: Biofeedback therapy has been used to treat the symptoms of people with chronic constipation referred to specialist services within secondary and tertiary care settings. However, different methods of biofeedback are used within different centres and the magnitude of suggested benefits and comparable effectiveness of different methods of biofeedback has yet to be established. OBJECTIVES: To determine the efficacy and safety of biofeedback for the treatment of chronic idiopathic (functional) constipation in adults. SEARCH METHODS: We searched the following databases from inception to 16 December 2013: CENTRAL, the Cochrane Complementary Medicine Field, the Cochrane IBD/FBD Review Group Specialized Register, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsychINFO. Hand searching of conference proceedings and the reference lists of relevant articles was also undertaken. SELECTION CRITERIA: All randomised trials evaluating biofeedback in adults with chronic idiopathic constipation were considered for inclusion. DATA COLLECTION AND ANALYSIS: The primary outcome was global or clinical improvement as defined by the included studies. Secondary outcomes included quality of life, and adverse events as defined by the included studies. Where possible, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. MAIN RESULTS: Seventeen eligible studies were identified with a total of 931 participants. Most participants had chronic constipation and dyssynergic defecation. Sixteen of the trials were at high risk of bias for blinding. Attrition bias (4 trials) and other potential bias (5 trials) was also noted. Due to differences between study populations, the heterogeneity of the different samples and large range of different outcome measures, meta-analysis was not possible. Different effect sizes were reported ranging from 40 to 100% of patients who received biofeedback improving following the intervention. While electromyograph (EMG) biofeedback was the most commonly used, there is a lack of evidence as to whether any one method of biofeedback is more effective than any other method of biofeedback. We found low or very low quality evidence that biofeedback is superior to oral diazepam, sham biofeedback and laxatives. One study (n = 60) found EMG biofeedback to be superior to oral diazepam. Seventy per cent (21/30) of biofeedback patients had improved constipation at three month follow-up compared to 23% (7/30) of diazepam patients (RR 3.00, 95% CI 1.51 to 5.98). One study compared manometry biofeedback to sham biofeedback or standard therapy consisting of diet, exercise and laxatives. The mean number of complete spontaneous bowel movements (CSBM) per week at three months was 4.6 in the biofeedback group compared to 2.8 in the sham biofeedback group (MD 1.80, 95% CI 1.25 to 2.35; 52 patients). The mean number of CSBM per week at three months was 4.6 in the biofeedback group compared to 1.9 in the standard care group (MD 2.70, 95% CI 1.99 to 3.41; 49 patients). Another study (n = 109) compared EMG biofeedback to conventional treatment with laxatives and dietary and lifestyle advice. This study found that at both 6 and 12 months 80% (43/54) of biofeedback patients reported clinical improvement compared to 22% (12/55) laxative-treated patients (RR 3.65, 95% CI 2.17 to 6.13). Some surgical procedures (partial division of puborectalis and stapled transanal rectal resection (STARR)) were reported to be superior to biofeedback, although with a high risk of adverse events in the surgical groups (wound infection, faecal incontinence, pain, and bleeding that required further surgical intervention). Successful treatment, defined as a decrease in the obstructed defecation score of > 50% at one year was reported in 33% (3/39) of EMG biofeedback patients compared to 82% (44/54) of STARR patients (RR 0.41, 95% CI 0.26 to 0.65). For the other study the mean constipation score at one year was 16.1 in the balloon sensory biofeedback group compared to 10.5 in the partial division of puborectalis surgery group (MD 5.60, 95% CI 4.67 to 6.53; 40 patients). Another study (n = 60) found no significant difference in efficacy did not demonstrate the superiority of a surgical intervention (posterior myomectomy of internal anal sphincter and puborectalis) over biofeedback. Conflicting results were found regarding the comparative effectiveness of biofeedback and botulinum toxin-A. One small study (48 participants) suggested that botulinum toxin-A injection may have short term benefits over biofeedback, but the relative effects of treatments were uncertain at one year follow-up. No adverse events were reported for biofeedback, although this was not specifically reported in the majority of studies. The results of all of these studies need to be interpreted with caution as GRADE analyses rated the overall quality of the evidence for the primary outcomes (i.e. clinical or global improvement as defined by the studies) as low or very low due to high risk of bias (i.e. open label studies, self-selection bias, incomplete outcome data, and baseline imbalance) and imprecision (i.e. sparse data). AUTHORS' CONCLUSIONS: Currently there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of biofeedback for the management of people with chronic constipation. We found low or very low quality evidence from single studies to support the effectiveness of biofeedback for the management of people with chronic constipation and dyssynergic defecation. However, the majority of trials are of poor methodological quality and subject to bias. Further well-designed randomised controlled trials with adequate sample sizes, validated outcome measures (especially patient reported outcome measures) and long-term follow-up are required to allow definitive conclusions to be drawn.

Community nursing and intermittent self-catheterisation.

Clean intermittent self-catheterisation (CISC) is a treatment option for people with urinary incontinence-particularly those with neurogenic bladder dysfunction. When used for appropriate patients it has been shown to promote continence, maintain safe bladder function and improve quality of life. There is a range of different products available on prescription for patients, and community nurses are ideally placed to advise them regarding products and to offer choice to those performing CISC. CISC can promote privacy and dignity for patients with urinary incontinence due to impaired bladder emptying, and community nurses should offer this intervention to patients for whom it is suitable and support them in learning the technique.

Effectiveness of alcohol brief interventions in general practice.

Harmful levels of alcohol consumption are a longstanding but continually growing health concern affecting individuals, and consequently populations. Through personalised advice, alcohol brief interventions (ABIs) target drinking habits, which are deemed damaging to health. They are not targeted at dependent drinkers for whom a more intensive and specialist service would be better suited. In response to recent shifts in public-health strategy away from ABIs, and the publication of new trials into their effectiveness, this article evaluates the value of ABIs through the review of eleven relevant studies. Findings suggest that hazardous drinkers did reduce their drinking patterns following ABI, but not more so than control participants who were given standard treatment. The evolution of standard treatment to include thorough screening, non-personalised advice and sometimes literature on alcohol intake delivers an intervention, that is effective in reducing drinking. Therefore, future research and practice should focus on screening methods and quality of standard care rather than on brief interventions.

Catheter valves: a welcome alternative to leg bags.

Catheterisation is commonly used to manage long-term bladder drainage. If intermittent catheterisation is not possible an indwelling urethral or suprapubic catheter will be used. There are a choice of drainage systems for use with indwelling urinary catheters including bed bags, link systems and catheter valves. Catheter valves are not suitable for everybody and patient assessment is vital: only patients with the cognitive ability and manual dexterity to operate a valve should be offered this option for bladder drainage. Catheter valves offer a number of advantages over drainage bags including improved privacy and dignity, prevention of bladder-neck trauma, reduced catheter encrustation and maintenance of normal detrusor muscle function. A number of catheter valves are available, including the EZ-Flow valve, and patient choice is important when selecting an appropriate product.

Exploring the role of the inflammatory bowel disease nurse specialist.

The number of inflammatory bowel disease (IBD) nurses and the amount of biological therapies being used in IBD has proliferated over the past ten years. Coordinating and managing a biologics service requires highly skilled specialist nursing knowledge and awareness of the support, assessment, administration and monitoring required in supporting the patient through this pathway. This article explores the role of the nurse and clinical issues in managing patients receiving biological therapies.