Sue Woodward

Yield and cost effectiveness of mycobacterial infection detection using a simple IGRA-based protocol in UK subjects with inflammatory bowel disease suitable for anti-TNFα therapy

BACKGROUND AND AIMS Testing for LTBI is recommended prior to anti-TNFα agents. This includes an assessment of TB risk factors, chest radiograph, and interferon-gamma release assay alone or with concurrent Tuberculin skin testing. Here we review our experience and cost-effectiveness of using T-SPOT.TB IGRA to detect mycobacterial infection in patients with IBD suitable for anti-TNFα therapy. METHODS This was a single-centre, retrospective review and economic evaluation (compared to British Thoracic Society guidance) of 125 adult IBD patients (90 anti-TNFα naïve, 35 established on anti-TNFα) tested for LTBI using T-SPOT.TB IGRA. RESULTS All subjects had normal chest radiographs and no clinical evidence for TB. 109 (87%) were BCG vaccinated. 27 (22%) of all patients tested were not using immunomodulation at the time of testing. 66 (53%) were taking thiopurines, 22 (18%)corticosteroids, and 35 (28%) anti-TNFα agents. One hundred twenty two (98%) had a negative IGRA result, two (2%) had positive results, and one (1%) had an indeterminate IGRA. A strategy using IGRA to guide TB preventative treatment produced cost savings of £10.79 per person compared to the BTS guidance. Eighty eight percent of the anti-TNFα naïve group have subsequently received treatment with either infliximab or adalimumab (median follow-up of 24 months, IQR 18-30) with no cases of TB disease occurring. CONCLUSIONS The use of a simple screening protocol for LTBI incorporating T-SPOT.TB IGRA in place of TST in a largely BCG vaccinated population, many using immunomodulatory agents, appears to work well and is a cost-effective strategy in our IBD service.

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.

“It’s just horrible”: a qualitative study of patients’ and carers’ experiences of bowel dysfunction in multiple sclerosis

Around 50% of people with multiple sclerosis (MS) experience neurogenic bowel dysfunction (constipation and/or faecal incontinence), reducing quality of life and increasing carer burden. No previous qualitative studies have explored the experiences of bowel problems in people with MS, or the views of their family carers. This study sought to understand ‘what it is like’ to live with bowel dysfunction and the impact this has on people with MS and carers. Using exploratory qualitative methods, 47 semi-structured interviews were conducted with participants recruited from specialist hospital clinics and community sources using purposive and chain-referral sampling. Data were analysed using a pragmatic inductive-deductive method. Participants identified multiple psychological, physical and social impacts of bowel dysfunction. Health care professional support ranged from empathy and appropriate onward referral, to lack of interest or not referring to appropriate services. Participants want bowel issues to be discussed more openly, with clinicians instigating a discussion early after MS diagnosis and repeating enquiries regularly. Bowel dysfunction impacts on the lives of people with MS and their carers; their experience with care services is often unsatisfactory. Understanding patient and carer preferences about the management of bowel dysfunction can inform clinical care and referral pathways.

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.

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.

Selecting and fitting a penile sheath

Correct application of sheaths Different sheath systems perform differently and not all external continence devices are suitable for all patients (Pemberton et al, 2006). It is vital that the correct size is measured and fitted as this will help to eliminate many of the problems with leakage and sheaths falling off. The circumference of the shaft of the penis should be measured immediately behind the glans penis (Figure 1) using the measuring device that is supplied by the manufacturer. The length of sheath required should also be given careful consideration. Sheaths are available in standard and shorter lengths, but if the penis is retracted too much then a device that adheres to the glans penis, such as BioDerm® (CliniMed), may be applied (Woodward, 2007). The sheath should be applied to clean, dry skin that has no talcum powder or creams applied as these products can affect the adhesive properties and increase the risk that the sheath will fall off or leak. Pubic hair should not be shaved as this may cause skin irritation, but hair may be trimmed with scissors. Alternatively a hair guard may be used to keep pubic hair away from the adhesive (Stubbs, 2008). These small paper devices have a central hole and may be supplied by the manufacturer, but if not available a small hole can be torn in the centre of a paper towel and will serve the same purpose. The sheath should always be applied leaving a gap between the tip of the penis and the funnel of the sheath to allow for urine to flow without the sheath ‘ballooning’, which could result in the sheath leaking or coming off. This also reduces Urinary incontinence and associated symptoms can sometimes be cured, often improved and almost invariably better managed. Many men who experience episodes of urinary incontinence will resort to using some sort of product for containment to protect their clothes or dignity (Fader et al, 2008) and there are a plethora of products from which to choose. These products may be used in the short term, while the incontinence is treated using another intervention, or long term; they may be worn day and night or only occasionally, e.g. when going out. Men with urinary incontinence are often embarrassed about reporting this symptom and may attempt to manage the urine loss independently of health professionals, choosing to buy incontinence products privately. Decision making is then influenced by product availability, cost and comfort, but most men have limited knowledge and access to a limited range of products (Paterson et al, 2003). It is vital, therefore, that nurses are product-aware and able to support patients in choosing the most appropriate products to meet their needs. The primary aim in managing urinary incontinence is to improve the quality of life for the patient and to ensure that urine is contained securely in a manner that is acceptable to the patient (National Institute for Health and Care Excellence, 2010), while protecting the integrity of the skin. If a male patient has been assessed, is emptying his bladder fully, and is suffering from moderate to severe intractable incontinence, an external continence device may be used and may be more acceptable to the patient than wearing an absorbent pad (Chartier-Kastler et al, 2011). Wearing an external urine drainage system also has obvious advantages over indwelling urethral catheters for men. One large-scale randomised controlled trial (Saint et al, 2006) found an 80% reduction in urinary tract infections when using a penile sheath rather than an indwelling urethral catheter.

Development and Psychometric Properties of the Inflammatory Bowel Disease Distress Scale (IBD-DS): A New Tool to Measure Disease-Specific Distress

Background Inflammatory bowel disease (IBD) imposes a heavy psychosocial burden, with many patients reporting anxiety, depression, and distress. In diseases such as diabetes, disease-specific distress is associated with concordance with treatments and disease control. IBD distress, distinct from anxiety and depression, is evident in people with IBD. We aimed to develop a questionnaire for assessing IBD-specific distress, validate this against a gold standard distress measure for diabetes, and demonstrate the difference between anxiety, depression, and distress. Methods The 94-item IBD Distress Scale (IBD-DS) was developed through secondary analysis of 3 qualitative data sets from previous IBD studies. Items were then refined through cognitive interviews in 2 stages (n = 15, n = 3). Three supplementary unscored questions were added to enable patients to identify their overall level of distress, their perceived level of disease activity, and their 3 most distressing issues. Subsequently, the 55-item IBD Distress Scale was subjected to test-retest. Two hundred seventy-five people received the test draft IBD-DS, and 168 responded (60.4%). Of these, 136 (82%) returned the retest draft of IBD-DS 3 weeks later. After analysis, further item reduction was informed by response rates, kappa values, and correlation coefficients, and test-retest was repeated. One hundred fifty-four people received the test final 28-item IBD-DS, and 123 people responded (58.8%). Of these, 95 (77%) returned the retest final IBD-DS. Results The 94 items were reduced to 28 items. Good intraclass correlation (ICC) was found between test-retest scores on 72 complete data sets with unchanged disease status (ICC, 0.92; 95% confidence interval, 0.88-0.95). Cronbachs alpha was 0.95, indicating excellent internal consistency. Factor analysis indicated scoring the items as a single domain (score range, 0-168). Conclusion The final IBD-DS performs well and offers a tool for assessing IBD-specific distress.

Supporting patients to manage faecal incontinence

of an underlying problem and is defined as involuntary leakage or any involuntary loss of faeces (solid or liquid) that is a social or hygienic problem (National Institute for Health and Care Excellence), 2007). FI and/or urgency is thought to affect approximately 10% of adults in the UK (NICE, 2007) and this can have a devastating impact on quality of life. Prevalence increases with age and in some patient groups (Box 1). Outside these groups, it is more common in women, where it is usually associated with obstetric injury to the pelvic floor. It is also a frequent complication of pelvic organ prolapse, colonic resection or anal surgery, pelvic radiotherapy and ingestion of some medications. FI is often more difficult to control if the patient has loose stool or diarrhoea (NICE, 2007). Bowel continence requires an individual to sense when the rectum is filling, store the faecal material for a period of time and prevent unwanted leakage from the anus. Bowel continence is maintained by the closure of the internal and external anal sphincters and adequate functioning of the muscles of the pelvic floor (Woodward, 2012). Neurological disorders or trauma can result in faecal incontinence as the nervous supply to the muscles of the pelvic floor and anal sphincters is impaired. This may result in a lax anus and passive leakage, depending on the level of neurological damage (Norton and Chelvanayagam, 2004). In some cases of faecal incontinence the pelvic floor and anal sphincter muscles are intact and functioning normally. Faecal incontinence can also occur as the result of other factors such as profuse diarrhoea, constipation and faecal impaction (which distends the anal sphincters) with faecal fluid overflow. Loss of motivation to maintain continence or cognitive decline can also result Supporting patients to manage faecal incontinence

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.