Bowel Training Research Articles

Effectiveness of acupoint stimulation combined with neurogenic bowel training on constipation in stroke patients: a retrospective study

Objective To analyze the effectiveness of acupoint stimulation combined with neurogenic bowel training on constipation in stroke patients. Methods A retrospective analysis was conducted on the clinical data of 89 stroke patients with constipation admitted to our hospital from July 2022 to January 2024. All patients met the inclusion and exclusion criteria. The control group (n = 42) received neurogenic bowel training intervention, while the experimental group (n = 47) received finger acupoint stimulation combined with neurogenic bowel training intervention. Four outcome measures including intervention effects, bowel movements, Constipation Scoring System (CSS), and Scores on the Patient Assessment of Constipation Quality of Life (PAC-QOL) were compared between the two groups. Results The total intervention effective rate in the experimental group (91.49%) was significantly higher than that in the control group (73.81%) (p < 0.05). Two weeks after intervention, the experimental group had significantly better first bowel movement time, average bowel movement time, and bowel movement interval time compared to the control group (p < 0.05). One and 2 weeks after intervention, the CSS and PAC-QOL scores in the experimental group were significantly better than those in the control group (p < 0.05). Conclusion Acupoint stimulation combined with neurogenic bowel training significantly improves constipation in stroke patients. Compared to neurogenic bowel training alone, the combined application of acupoint stimulation further improves bowel movements, reduces constipation severity, and enhances the quality of life in patients. Therefore, it is worthy of clinical promotion.

Developing a Cell-Microcarrier Tissue-Engineered Product for Muscle Repair Using a Bioreactor System.

Fecal incontinence, although not life-threatening, has a high impact on the economy and patient quality of life. So far, available treatments are based on both surgical and nonsurgical approaches. These can range from changes in diet, to bowel training, or sacral nerve stimulation, but none of which provides a long-term solution. New regenerative medicine-based therapies are emerging, which aim at regenerating the sphincter muscle and restoring continence. Usually, these consist of the administration of a suspension of expanded skeletal-derived muscle cells (SkMDCs) to the damaged site. However, this strategy often results in a reduced cell viability due to the need for cell harvesting from the expansion platform, as well as the non-native use of a cell suspension to deliver the anchorage-dependent cells. In this study, we propose the proof-of-concept for the bioprocessing of a new cell delivery method for the treatment of fecal incontinence, obtained by a scalable two-step process. First, patient-isolated SkMDCs were expanded using planar static culture systems. Second, by using a single-use PBS-MINI Vertical-Wheel® bioreactor, the expanded SkMDCs were combined with biocompatible and biodegradable (i.e., directly implantable) poly(lactic-co-glycolic acid) microcarriers prepared by thermally induced phase separation. This process allowed for up to 80% efficiency of SkMDCs to attach to the microcarriers. Importantly, SkMDCs were viable during all the process and maintained their myogenic features (e.g., expression of the CD56 marker) after adhesion and culture on the microcarriers. When SkMDC-containing microcarriers were placed on a culture dish, cells were able to migrate from the microcarriers onto the culture surface and differentiate into multinucleated myotubes, which highlights their potential to regenerate the damaged sphincter muscle after administration into the patient. Overall, this study proposes an innovative method to attach SkMDCs to biodegradable microcarriers, which can provide a new treatment for fecal incontinence.

Multidisciplinary co-development of a chronic constipation management education programme for older people with dementia and the establishment of a model facility

Chronic constipation (CC) is prevalent among the elderly population and particularly those with dementia. Associate Professor Tomoyoshi Naito, School of Nursing, Seirei Christopher University, Japan, is exploring supportive care of elderly patients with dementia. He is working with collaborators to develop a multidisciplinary CC management education programme for healthcare professionals involved with elderly patients suffering from dementia. The researchers will also build a model facility to implement and verify the impact of the programme. Part of this research concerns gaining a more in-depth understanding of management and care techniques, based on the Japanese Chronic Constipation Treatment Guidelines from 2017, especially in relation to the diet and differentiation of chronic functional constipation. The goal is to reduce the number of painful medical procedures by enhancing therapy, exercise therapy, lifestyle guidance and making it possible to select step-by-step drug therapy. The programme will be executed at two facilities in Japan, targeting specialist caregivers who work with elderly patients with dementia, including doctors, nurses, pharmacists and other healthcare professionals. They will receive basic education on chronic constipation in elderly people with dementia, as well as practical training on the management of CC in addition to self-training and evaluations based on case studies. In a randomised controlled trial, Naito sought to verify the impact of bowel training as a treatment for CC and found that, together with the training, encouraging patients to use appropriate defecation posture significantly improved the condition. This was associated with a corresponding improvement in the mental health and wellbeing of patients and caregivers.

Abdominal massage and laxative use for constipation: a pilot study.

Constipation is a very frequent condition. Pharmacological treatment leads to the onset of complications in the long term. To study the effects of abdominal massage and bowel training combined with polyethene glycol compared with laxative alone. Researchers studied the frequency of evacuations, use of laxatives, appetite, and food intake of older persons. In addition, feasibility in the daily routine of nursing care was studied. A pilot, randomised controlled trial was conducted. Older people living in a facility for self-sufficient residents were enrolled and randomised to the intervention or control group. The massage was administered for 4 weeks. The stool type according to the Bristol Stool Form Scale and secondary outcomes were collected at baseline, before any massage session and at the end of the intervention. 32 participants were enrolled. Significant improvements were found in the number of evacuations, need for enemas, Bristol scores, appetite and food intake. Significant improvements were found in all major outcomes.

Research in Brief

Bowel training and improving defecation posture can benefit patients with dementia who are suffering from chronic constipation, improving their mental health and reducing the burden on care givers, new research suggests. Tomoyoshi Naito and colleagues randomly assigned patients to receive either bowel training and a defecation posture intervention (n=14) or general care (n=16). At 8 weeks, the mean number of complete spontaneous bowel movements per week increased from 0·53 to 1·58 movements in the intervention group whilst decreasing from 0·56 to 0·43 movements in the general care group (pinteraction<0·001).

Cross-mapping medical records to NANDA-I to identify nursing diagnoses in a vulnerable population.

To assess the association between vulnerable populations and nursing care needs, using NANDA-I diagnostics, in the population of the Canary Islands, Spain. Nursing social epidemiology study. Cross Mapping of Medical Records to NANDA-I to Identify Nursing Diagnoses in a Population usinga medical, epidemiological follow-up study of a cohort of 7,190 people. The level of vulnerability of the participants was assigned, among those who were also assigned nursing diagnoses, using the "ICE index" to calculate the expected associations. The most prevalent nursing diagnosis in our sample was Sedentary lifestyle (60.5%), followed by Ineffective health self-management (33.8%) and Risk-prone health behaviour (28.7%). Significant differences were found by sex, age group and social class, with the nursing diagnoses included in the study being more prevalent among the most socio-economically disadvantaged social class. The cross-mapping method is useful to generate diagnostic information in terms of care needs, using the NANDA-I classification. The expected associations between high social vulnerability and care needs have been verified in a comprehensive and representative sample of the Canarian population (Spain). From an epidemiological perspective, identifying nursing diagnoses at the population level allows us to find the most prevalent needs in the different community groups and to focus appropriate nursing interventions for their implementation and impact assessment.

Evaluation of a bladder and bowel training program for therapy-resistant children with incontinence

Daytime urinary incontinence (DUI) and fecal incontinence (FI) are common disorders in children. Although standard treatment is highly effective, subgroups of incontinence (combinations of nocturnal enuresis (NE), DUI and/or FI, or with psychological comorbidity) can relapse or take a chronic course. For these complex, therapy-resistant cases, a manualized outpatient bladder and bowel training program was developed. The aim of the study was to evaluate prospectively treatment effects of this training program, including a follow-up assessment. The training program was developed for small groups of 2-6 children (of same age and sex) aged 5-12 years with adaptations for 13-16 year-old adolescents. It consists of 7-9 weekly sessions for group training and 3 weekly sessions for individual training. The training comprises information about anatomy/physiology of the urogenital tract, pathophysiology, hygiene and balanced nutrition. Voiding and drinking diaries, stress management, relaxation and emotion regulation techniques are also included. Data of 32 children (mean age 8.6 years, range 5-13 years; 21 boys), who had received standard treatment (and did not reach complete response) are presented. 14 children received group therapy, 18 (younger children) were treated individually. Children were assessed before and after the treatment, as well as at a follow-up of 6 months later. Treatment effects were measured by incontinence frequency and treatment success according to the ICCS (complete response: 100% reduction of symptoms; partial response: 50-99% reduction of symptoms). Psychological symptoms were measured by the Child Behavior Checklist questionnaire (CBCL). Frequencies of DUI were significantly reduced from 5.7 wetting episodes/week (before training) to 4.9 (after training) to 2.0 (6 months after training). Frequencies of FI were reduced from 2.9 soiling episodes/week (before training) to 1.9 (after training), but increased to 2.6 (6 months after training). According to the ICCS classification, 11.1% of children with DUI had a complete response after training and 47.6% at follow-up after 6 months. In children with FI, 33.3% reached a complete response at the end of the training and 25% at follow-up. Additionally, psychological symptoms, especially internalizing, decreased significantly during training. Further, in 14 children with comorbid NE, nighttime wetting reduced from 5.9 before training to 1.5 episodes/week at follow-up. This bladder and bowel training program is an effective and successful treatment option for children with therapy-resistant subtypes of incontinence. Symptoms still improved 6 months after training in DUI. Additionally, the training program is helpful to decrease psychological symptoms.

Nurse- and Pelvic Floor Physical Therapist-Led Bowel Training in Patients With Fecal Incontinence in a Tertiary Care Center.

Little is known about nurse- and pelvic floor physical therapist-led bowel training in fecal incontinence after previous conservative management has been deemed unsatisfactory. The objective of this study was to evaluate combined nurse- and physical therapist-led bowel training sessions in a tertiary care center. This was a prospective, cross-sectional study. All patients with fecal incontinence between 2015 and 2016 with and without previous conservative management were included. Combined conservative treatment was defined as the use of stool-bulking agents (psyllium fibers) with or without antidiarrheal medication (loperamide) in combination with biofeedback or pelvic floor muscle training. Questionnaires regarding fecal incontinence (Vaizey incontinence score) and quality of life (Short Form Health Survey-36) were used. A decrease in the Vaizey incontinence score of 5 or more points was deemed to be clinically significant. Vaizey incontinence scores in all 50 patients decreased from 14.7 (SD = 4.5) to 9.9 (SD = 4.8) at follow-up (p < .001). Forty percent of patients reported an improvement in their Vaizey incontinence score (change of 5 or more points). Improvement was noted in those with and without previous treatment. Quality of life improved significantly. The limitation of the study includes lack of a standardized treatment protocol. Fecal incontinence reduced after nurse- and physical therapist-led bowel training sessions in patients with and without previous treatment, increasing their quality of life.

Rehabilitation Program for Spinal Cord Injury Neurological Level C2 due to Foramen Magnum Meningioma

Introduction: Foramen magnum meningioma is a rare case. The incidence is 0.3% - 3.2% of all meningiomas. Clinical manifestations of foramen magnum meningioma are atypical and unpredictable. The main therapy for foramen magnum meningioma is surgery. The role of rehabilitation becomes important in the process after surgery.&#x0D; Case Presentation: A 46 years old female had weakness and loss of sensory of her upper and lower limbs, accompanied by urinary retention and constipation in the last 2 month, categorized by ASIAimpairment scale (AIS) C neurological level of injury at C2. Cervical MRI with contrast showed the impression of an extramedullary intradural mass as high as the inferior aspect of the pons to the corpusvertebrae cervical 1 supports the picture of meningiomas. The rehabilitation programs after surgery were active assistive range of motion exercise progressing to active range of motion, neuromuscular electrical stimulation, sensory stimulation and bladder and bowel training.&#x0D; Conclusion: The patient’s expectation for returning to independency is a long-term goal of the rehabilitation program. After definitive therapy (surgery) is conducted, medical rehabilitation management can be done as early as possible to achieve the optimum functional recovery. Muscle strengthening, sensory stimulation and bladder/bowel training improved motor , sensory and autonomic function.

Consensus statement on bladder training and bowel training

AbstractAimThis consensus statement synthesizes evidence to guide healthcare professionals on promoting consistent, cohesive and achievable bladder training for people with overactive bladder/urgency urinary incontinence and bowel training for those with urgency fecal incontinence.MethodsThe Consensus Statement on Bladder and Bowel Training was developed by a sub‐group of the International Continence Society Nursing Committee and an expert panel, who formed a virtual Consultation Group. Review of published research, expert opinion articles, policy statements, and voluntary professional group information identified existing recommendations, from which statements were formulated and organized. A modified Delphi process was used to reach consensus on each statement, involving three rounds of virtual consultation. Consultation Group members indicated agreement/disagreement with each statement. Statements, or changes, were accepted when consensus was reached, defined as agreement by 80% of the Consultation Group.ResultsNo universal definition of bladder training or bowel training was found, therefore a consensus definition was developed and agreed for each. Limited high quality studies of bladder training were identified and no studies investigating the use or effectiveness of bowel training for urgency fecal incontinence in adults. Broad‐ranging evidence suggests both types of training should include four elements, personalized to individual need and situation: information and education; a prescribed voiding/evacuation regimen based on individually identified patterns of bladder or bowel functioning; progression of voiding/evacuation regimen; ongoing support and reinforcement.ConclusionsThese consensus statements will support healthcare practitioners to design and deliver consistent bladder and bowel training. Improved evidence on mechanisms and effectiveness is needed to inform practice.

Intestinal dysfunction of spinal cord injury treated with tongdu tiaoshen moxibustion: a randomized controlled trial

To compare the clinical effect on intestinal dysfunction of spinal cord injury (SCI) between the comprehensive therapy of tongdu tiaoshen moxibustion (moxibustion for opening the governor vessel and regulating the spirit) and rehabilitation training and the simple treatment with rehabilitation training. A total of 60 patients with intestinal dysfunction of SCI were randomized into a comprehensive therapy group and a rehabilitation group, 30 cases in each one (3 cases were dropped out in each group). On the base of the routine western medicine treatment and rehabilitation training, the bowel training and rectal function training were provided, once a day in the rehabilitation group. In the comprehensive therapy group, on the base of the treatment as the rehabilitation group, the tongdu tiaoshen moxibustion was exerted at Yaoyangguan (GV 3), Mingmen (GV 4), Zhiyang (GV 9), Dazhui (GV 14) and Baihui (GV 20), etc, once a day, 30 min each time. In both groups, the treatment for 4 weeks was as one course and 3 courses of treatment were required. Separately, before treatment, after 4, 8 and 12 weeks of treatment, the scores of neurogenic bowel dysfunction (NBD) and World Health Organization quality of life scale (WHOQOL-BREF) were observed and the clinical effect was evaluated after 12 weeks of treatment. After treatment, the total effective rate was 88.9% (24/27) in the comprehensive therapy group, which was higher than 74.1% (20/27) in the rehabilitation group (P<0.05). After 4, 8 and 12 weeks of treatment, NBD scores were all reduced obviously as compared with those before treatment in the two groups (all P<0.01). After 8 and 12 weeks of treatment, NBD scores in the comprehensive therapy group were lower than the rehabilitation group (both P<0.05). After 4, 8 and 12 weeks of treatment, the scores of all of the domains (psychology, physiology, social relations and environment) in WHOQOL-BREF were higher than those before treatment in the two groups (all P<0.01). After 4 weeks of treatment, the scores in the psychology and physiology domains in the comprehensive therapy group were higher than the rehabilitation group (all P<0.05). After 8 and 12 weeks of treatment, the scores of all of the domains in the comprehensive therapy group were higher than the rehabilitation group (all P<0.05). The comprehensive treatment of tongdu tiaoshen moxibustion and rehabilitation training achieves the better effect on intestinal dysfunction of SCI than the simple rehabilitation training and greatly improves the quality of life in SCI patients.

Toilet Training in Fragile X Syndrome.

To characterize bladder and bowel toileting skill acquisition in children with fragile X syndrome and to identify associated demographic, behavioral, and clinical factors. Using baseline data from the Fragile X Online Registry With Accessible Research Database (FORWARD), bivariate analyses and logistic regression models were used to identify differences between subjects who were and were not bowel and/or bladder trained by the age of 10 years. Cox proportional hazard models were used to assess the rate of completion of toilet training (TT) as a function of sex and autism spectrum disorder (ASD) diagnosis. In bivariate analyses, male sex, lower language level, inability to write one's name, more impaired intellectual level, ASD, and more severe behavioral deficits all predicted lack of bladder training (n = 313, p < 0.001) and bowel training (n = 300, p = 0.0004-0.0001) by the age of 10 years. In logistic regression models, lower level of language acquisition (p < 0.001) and higher Aberrant Behavior Checklist Irritability scores (p < 0.04) were associated with lower odds of bladder training by the age of 10 years. Lower level of language acquisition (p < 0.001) and ASD (p < 0.025) were associated with lower odds of bowel training by the age of 10 years. For both bladder and bowel training, Cox proportional hazard models indicated that delayed training was associated with male sex, lower levels of language acquisition, and ASD for both bladder training (n = 486; p < 0.001) and bowel training (n = 472; p < 0.001). These findings emphasize the importance of both slower language development and ASD diagnosis in predicting bowel and bladder training delays and can be used to develop and evaluate targeted approaches to TT based on sex, ASD diagnosis, and other clinical features identified in this study.

Nurse-run clinic for functional bowel disorders at a district general hospital

Background: Functional bowel disorders (FBDs) include constipation, diarrhoea, bloating and unspecified FBD. FBDs have serious symptoms that impact quality of life and require effective resource management to reduce their impact on clinical services. Aim: The experience of a nurse-led FBD service in a UK district general hospital is presented. The service is protocol driven and led by a colorectal clinical nurse specialist (CNS), with appropriate consultant supervision. Referrals are from primary care and consultant clinicians. Method: Demographics, investigations, treatments and outcomes were analysed using a prospectively run database of the clinic's patients from 2005 to 2016. Results: There were records of 980 patients (median age 56 years; 115M:865F); 60.1% had diarrhoea alone, 36.5% had constipation alone and 3.4% had both. Investigations included barium enema, endoanal ultrasound and transit study. Treatments included rectal irrigation (59.7%), laxative (53.2%), enema (12.3%), anti-diarrhoeal (6%), bowel training (2.4%) or another drug (1.8%). Conservative management was successful in most patients, and only 83 (8.4%) patients were referred for surgery. Conclusion: The nurse-led service is safe, effective and has good outcomes, with a low surgery conversion and high patient satisfaction.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.

Intractable Constipation in the Elderly.

Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.

The Effectiveness of Abdominal Massage on Neurogenic Bowel Dysfunction in Patients With Spinal Cord Injury: A Systematic Review

Neurogenic bowel dysfunction is a common comorbidity in spinal cord injury patients that may result in fecal incontinence. Abdominal massage is one intestinal training method that is used to improve bowel movement and defecation. To review the effectiveness of abdominal massage on neurogenic bowel dysfunction in patients with spinal cord injury. A systematic review of Chinese and English-language articles was performed in six databases using the following key words: spinal cord injury, abdominal massage, neurogenic bowel dysfunction, and bowel training. Relevant studies published prior to June 2016 that met the inclusion and exclusion criteria were selected. The Downs and Black scale was used to appraise the quality of each of the included studies. Eight studies were included in the final analysis. Four of these studies indicated that abdominal massage significantly improved bowel functions and the regularity and frequency of bowel movements. Although two of the studies indicated that abdominal massage significantly reduced the use of glycerin and laxatives, the remaining six did not. The eight studies earned respective quality scores ranging between 13 and 25. The current literature lacks consensus on the efficacy of abdominal massage in terms of improving bowel dysfunction in patients with spinal cord injuries. Future studies should use more stringent experimental designs such as randomized controlled studies to explore the correlations among massage time and frequency and bowel function improvements in order to provide guidelines for clinical care applications.

Certified Nursing Assistant and Care Assistant Views on Incontinence Care: Insights for the Creation of Quality Improvement Programs

Background: Incontinence is a prevalent condition affecting the health and quality of life of many elderly, particularly those living in institutional settings. Incontinence can lead to skin breakdown and infection and rates of occurrence of both are increasingly being used to assess facility quality. Certified nursing assistants (CNAs) and care assistants (CAs) provide most of the hands-on care in long-term care facilities, yet little is known about their views on managing incontinence. Aims: This study examined the knowledge and attitudes of CNAs and CAs regarding incontinence care to inform quality improvement (QI) programs related to this condition. Sample: The population consisted of 69 CNAs and 22 CAs, comprising 15 focus groups, from 32 facilities in Georgia in the southeastern United States (US). Methods: Experts in elder care, including social workers and physicians, consulted on the script and trained facilitators guided sessions. Data were subject to extensive content analysis to identify themes related to incontinence care. Results: The majority of CNAs and CAs cared for incontinent residents. Both groups were aware of risk factors for the condition, particularly the role of dementia and stroke. They were familiar with the standard clinical consequences, but emphasized the negative effect of incontinence on resident pride and well-being. Bladder and bowel training programs were viewed as highly effective treatments, but all groups stressed that learning resident toileting patterns was most important and could often prevent episodes. Areas for care improvement were: communication between shifts about resident toileting patterns; teamwork when the facility was shortstaffed to maintain toileting schedules; securing clothing that did not impede toileting; and notifications about changes in medications which affect toileting patterns. All staff agreed that some residents could avoid episodes, but did not want to. Conclusion: The findings here underscore that including CNAs and CAs in designing incontinence QI efforts is critical and one promising path may be to increase staff autonomy in managing the condition. Themes identified here also indicate the need to improve communication between staff, particularly across shifts, and with families. Such adaptations are likely to help reduce episodes and hence minimize negative sequelae from the condition.

Chronic constipation in the elderly: a primer for the gastroenterologist.

Constipation is a frequently reported bowel symptom in the elderly with considerable impact on quality of life and health expenses. Disease-related morbidity and even mortality have been reported in the affected frail elderly. Although constipation is not a physiologic consequence of normal aging, decreased mobility, medications, underlying diseases, and rectal sensory-motor dysfunction may all contribute to its increased prevalence in older adults. In the elderly there is usually more than one etiologic mechanism, requiring a multifactorial treatment approach. The majority of patients would respond to diet and lifestyle modifications reinforced by bowel training measures. In those not responding to conservative treatment, the approach needs to be tailored addressing all comorbid conditions. In the adult population, the management of constipation continues to evolve as well as the understanding of its complex etiology. However, the constipated elderly have been left behind while gastroenterology consultations for this common conditions are at a rise for the worldwide age increment. Aim of this review is to provide an update on epidemiology, quality of life burden, etiology, diagnosis, current approaches and limitations in the management of constipation in the older ones to ease the gastroenterologists’ clinic workload.

Factors Associated With Efficacy of Nurse-led Bowel Training of Patients With Chronic Constipation

It is not clear whether nurse-led bowel training (NBT), an individually tailored biofeedback strategy designed to improve the physiological process of defecation by operant conditioning and trial and error learning, is effective for patients with chronic constipation. We assessed the ability of NBT to reduce symptoms and increase quality of life in patients with constipation at a large tertiary medical center. We performed a retrospective analysis of data from 347 patients (median age, 50 years) who underwent a median 3 sessions of NBT for chronic constipation from January 2011 through December 2013 at St Marks Hospital in the United Kingdom. The NBT comprised a combination of sensory retraining, pelvic floor conditioning, and advice on diet and toileting behavior. Data on patient demographics (age, sex, type of constipation) were collected alongside their assessments of constipation, which were based on Patient Assessment of Constipation Quality of Life (PAC-QoL) and patient satisfaction scores. We performed binary logistic regression analysis. Each variable was tested first at the univariate level; those with significance (P < .10) were included in a multivariate model. At the end of NBT, 62.5% of the patients (217/347) reported reduced symptoms, and 40.2% of the patients (41/102) reported a reduction of at least 1 point on the PAC-QoL score. The mean PAC-QoL scores before and after NBT were 2.42 and 1.41, respectively (P = .001). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.02-2.87; P = .042), greater number of sessions (OR, 4.14; 95% CI, 2.09-8.20; P < .001), and non-irrigation (OR, 4.39; 95% CI, 1.89-10.19; P = .001) were independent predictors of patient satisfaction. Data collected immediately after patients with chronic constipation received NBT indicate that it is an effective treatment for most patients. Older patients with dyssynergic defecation benefit most from at least 4 sessions.

Repeated-dose oral N-acetylcysteine: Effect on brain and blood glutathione concentrations

CO RR EC TE D P RO OF practice in patients with MPS II. The records of twenty-one children with MPS II currently in our clinic were reviewed and the presence/ absence of the 7 key clinical markers of neurological function was noted (increased activity, behaviour difficulties, seizure-like behaviours, sleep problems, bladder training, bowel training and perseverative chewing). The score was repeated at sequential reviews from age at diagnosis until age 7 years or neurological involvement was obvious or until most recent assessment. Thirteen (65%) children developed CNS involvement. Median age at diagnosis due to symptoms was 30 months (range 10 to 72 months). Four children were diagnosed between birth and 8 months due to family history. Of the key clinical markers, behaviour and increased activity were the most frequently reported symptoms. The earliest features suggestive of neurological sub-type were sleep disturbance and aggressive behaviour. Increased activity and late bladder and bowel control were only observed in the neurological group. Abnormal chewing behaviour was never reported by parents. There were no seizure-like episodes in the whole cohort. This tool discriminated well between MPS II with and without neurological involvement in our patient cohort, however, the neurological phenotype was never diagnosed with clinical certainty before 3 years of age and more usually at 4 years. The presence of aggressive behaviour is likely a good indicator of impending neurological problems in MPS II. On the other hand several of the key factors of the scoring system such as seizure-like behaviour or bladder and bowel training were less helpful. Perseverative chewing was not present but this feature may not have been directly sought in the history. This study is limited by its historical review methodology and the scoring system should be tested prospectively. A scoring system does allow the paediatrician to make a focussed assessment of a newly diagnosed child. However, even with this focus it appears difficult to diagnose neurological MPS II clinically with any certainty before 3 years of age. Ultimately in order to benefit from new treatments aimed at the CNS, it is preferable that a biomarker is found. Holt J, Poe MD, Escolar ML: Early clinical markers of central nervous system involvement in mucopolysaccharidosis type II.: J Pediatr. 2011 Aug; 159(2): 320–6.