Systematic Review of Hypofractionated Radiation Therapy for the Treatment of Oesophageal Squamous Cell Carcinoma and Oesophageal Adenocarcinoma.

BACKGROUND AND AIM: There has been limited progress made in improving the suboptimal outcomes delivered by conventionally fractionated radiotherapy (RT) for oesophageal adenocarcinoma (OAC) and squamous cell carcinoma (OSCC). A greater biological effect may be achieved using hypofractionated RT (HFRT), though the toxicity, tolerability and efficacy of this approach in OAC and OSCC is uncertain. METHODS: A systematic literature review was carried out in accordance with Preferred Reporting Items for Systematic Reviews guidance. Medline, EMBASE, PubMed, Cochrane, CINAHL, Scopus and Web of Science databases were searched for terms relating to HFRT (>2.4Gy per fraction) for OAC or OSCC. All relevant clinical studies published between January 2000 and April 2023 were included. Study quality was assessed using predefined criteria. RESULTS: Ninety-six studies were screened and 20 subsequently included, together incorporating 1208 patients. Fourteen studies focussed on neoadjuvant or definitive treatment. These were predominantly retrospective (n = 10, 71%) though two (n = 2, 14%) early phase trials were identified. Most focussed on OSCC (n = 7, 47%) or mixed OSCC/OAC (n = 6, 43%) populations. Four (28.6%) included a conventionally fractionated chemoradiotherapy (CRT) comparator, against which median overall (mOS) and progression free survival outcomes from HFRT did not differ. Reported mOS for HFRT ranged between 29-36 months at 2.5-3.125Gy per fraction (total dose 50-60Gy) for OAC and OSCC combined. Toxicity and tolerability with HFRT was comparable with conventionally fractionated CRT up to, but not exceeding, 5Gy. Three (50%) of the six palliative-intent studies were early phase trials and most (n = 4, 67%) focussed on OAC and OSCC. Response rates with HFRT in the palliative setting were 63.6-88.0%. CONCLUSION: These data provide evidence in OAC/OSCC for promising efficacy and an acceptable toxicity profile for moderately HFRT, alone or with concurrent chemotherapy. These data should prompt prospective, randomised comparisons of HFRT and conventionally fractionated CRT and single-modality RT schedules. REGISTRATION DETAILS: PROSPERO; CRD42023457791.

Efficacy of lasers and light sources in long-term hair reduction: a systematic review.

Laser and light-based devices provide scope for long-term "hair-removal" however, there is limited evidence supporting their long-term efficacy. This study aimed to assess the long-term efficacy of laser and light-based "hair-removal" devices, taking into account variations in body site-specific variations in hair growthcycles. A systematic review of randomized controlled trials (RCTs) with follow-up periods greater than or equal to the length of one complete hair growth cycle in the body site targeted was conducted. Only five eligible RCTs were identified as suitable for inclusion, and these comprised a total of 223 patients. The average long-term hair reduction reported for neodymium:yttrium-aluminum-garnet (Nd:YAG) laser ranged from 30 to 73.61%, Alexandrite laser ranged from 35 to 84.25%, and Diode laser ranged from 32.5 to 69.2%. In all three devices, the greatest long-term reduction was observed from trials targeting leg hair (1-year growth cycle) and lowest from targeting facial hair (6-month growth cycle). Intense pulsed light (IPL) produced average long-term hair reduction of 52.7-27%; smallest reduction was observed from targeting the face area and greatest from targeting the axillary area (7-month growth cycle). In conclusion, greater long-term hair reduction was observed on body sites with longer hair growth cycles. Future trials should take into account the variation of hair growth cycles across body sites to provide accurate long-term data on treatment outcomes.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial.

BACKGROUND: Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences. METHODS: This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers. DISCUSSION: TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

A two phased study on health care professionals' perceptions of single or multi-use of intermittent catheters.

AIMS: This two phase study aimed to explore health care professionals' teaching and prescribing practice related to intermittent catheterisation and to identify their perceptions about the possible implementation of a mixed (single and multi-use) package for intermittent catheterization. INTRODUCTION: Single-use intermittent catheters are the norm in the UK although multi-use is common in some other countries. A recent Cochrane review found no difference in complications, including urinary tract infection rates, between those using single or multi-use catheters. A flexible option of both multi-use and single use intermittent catheters could provide users with more flexible choices in self-care. However, understanding health care professionals' perspectives is one of the keys to developing a multi-use intervention. DESIGN: A qualitative research framework using in-depth interviews to inform an on line survey. METHOD: In-depth interviews were conducted with health care professionals based in the UK who prescribe catheters, teach intermittent catheterisation or manage an intermittent catheterisation service. The interviewees were selected to represent a range of clinical areas, experience and professions - continence advisors, urology, multiple sclerosis (MS) and spinal cord injury specialist nurses, and General Practitioners. Following framework analysis the themes and factors identified were used to develop an on-line survey which was disseminated through health care professional networks whose members saw patients who use intermittent catheters. RESULTS: Nineteen health care professionals participated in the telephone interviews; 206 completed the survey. A wide range of professionals in terms of experience and specialty afforded rich information regarding the contextual issues around the teaching and prescribing of intermittent catheters. The primary finding was that health care professionals were concerned about 'minimising health risk' and maximising 'normalcy' for those using intermittent self-catheterisation. Health care professionals who worked in the acute setting or had no experience of re-use were most resistant to the re-use of catheters. Professionals requested evidence that a multi-use package would not increase the risk of developing a urinary tract infection or increase the burden of use to a patient before a mixed package would be considered. CONCLUSIONS: For multi-use to be acceptable, evidence based guidelines must be available for healthcare professionals and cleaning methods must be acceptable and safe for intermittent catheter users. Further evidence may be required to establish that a mixed catheter package is equivalent to single use only, particularly for outcomes such as urinary tract infection, urethral injury and quality of life. RELEVANCE TO CLINICAL PRACTICE: This paper highlights that if multi-use catheters are to be successfully introduced into clinical practice, the ease of use, safety and effectiveness of the cleaning technique will need to be convincingly demonstrated by a range of well-defined users.

Abdominal Massage for the Relief of Constipation in People with Parkinson's: A Qualitative Study.

Objectives. To explore the experiences of people with Parkinson's (PwP) who suffer from constipation, the impact this has on their lives, and the effect of using lifestyle changes and abdominal massage as a form of constipation management. Method. Fourteen semistructured interviews were completed (8 males and 6 females; mean age 72.2 years) at the end of a care programme, which consisted of either lifestyle advice and abdominal massage (intervention group; n = 7) or lifestyle advice only (control group; n = 7). Data were analysed using constant-comparison techniques and Framework methods. Themes and key quotes were identified to depict major findings. Findings. Four key themes were identified: (i) the adverse impact of bowel problems on quality of life; (ii) positive experience of behaviour adjustments: experimentation; (iii) abdominal massage as a dynamic and relaxing tool: experiential learning (intervention group only); (iv) abdominal massage as a contingency plan: hesitation (control group only). Constipation was reported as having a significant impact on quality of life. Participants in both groups perceived lifestyle advice to relieve symptoms. Specific improvements were described in those who also received the abdominal massage. Conclusions. Both lifestyle advice and abdominal massage were perceived to be beneficial in relieving symptoms of constipation for PwP.

Caring for continence in stroke care settings: a qualitative study of patients' and staff perspectives on the implementation of a new continence care intervention.

OBJECTIVES: Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke. DESIGN: Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis. SETTING: Mixed acute and rehabilitation stroke ward. PARTICIPANTS: Stroke patients and nursing staff that experienced an enhanced continence care intervention. RESULTS: Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence. CONCLUSION: Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

A multi-professional UK wide survey of undergraduate continence education.

OBJECTIVES: Findings from national audits and enquiries continue to report that care for patients with continence problems is often substandard and inadequate education is often cited as one of the probable causes. These factors combined with the forecasted increase in the number of people with incontinence prompted us to undertake a survey of all UK Higher Education Institutes (HEIs) to establish the amount of undergraduate continence education within relevant healthcare programs--medical, adult nursing, mental health nursing, learning disabilities nursing, children's nursing, midwifery, physiotherapy, and occupational therapy. DESIGN: An on line questionnaire targeted course program leads (n = 362) in all 86 HEIs in which undergraduate professional healthcare programs were provided (n = 362). MAIN OUTCOME MEASURE: Eighty-six HEIs were approached, 85 agreed to participate in the survey. A response rate of 81% (n = 294/362 programs) was obtained: 14% (n = 42) of respondents reported that there was no continence-related education within their undergraduate program. The mean number of hours was 4.7 (SD 4.3), and ranged from 2.5 (SD 3.5) hr (Occupational Therapy) to 7.3 (SD 4.8) hr (Adult Nursing). CONCLUSION: The survey results indicate that the amount of undergraduate education has changed little. Further research is needed to identify the most appropriate methods of delivering continence education and translate knowledge into improved patient outcomes. Adequate undergraduate continence education directed by the General Medical Council, Royal Colleges and Health Professional Council is required.

To what extent are national guidelines for the management of urinary incontinence in women adhered? Data from a national audit.

UNLABELLED: OBJECTIVE To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in women. DESIGN: Retrospective survey of consecutive female inpatients and outpatients with UI as part of a national audit. SETTING: NHS hospital and primary care (PC) trusts. POPULATION OR SAMPLE: Twenty-five women <65 years old and 25 women ≥ 65 years old from each participating site. METHOD: All NHS trusts in England, Wales and Northern Ireland were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous and access to the web-tool was password-protected for confidentiality. RESULTS: Data were returned by 128 acute and 75 PC trusts on 7846 women. No diagnosis was documented in 6.8% (153/2254) of younger and 28% (571/2011) of older women in hospitals (P < 0.001), and by 8.6% (123/1435) of younger and 21% (380/1786) of older women in PC trusts. In hospitals, 26% (396/1524) of younger women and 15% (182/1231) of older women (P < 0.001) and in PC trusts 8.2% (77/934) of younger and 4.7% (46/975) of older women underwent multichannel cystometry before conservative therapy. Documentation of discussion of causes and treatment of UI occurred in 76% (1717/2254) of younger and 44% (884/2011) of older women in hospitals (P < 0.001) and in 75% (1080/1435) of younger and 53% (948/1786) of older women in PC trusts (P < 0.001). CONCLUSION Older women are less likely to receive NICE compliant management. Adherence varies according to recommendation. There needs to be concentration on evidence-based community provision of care by competent and interested clinicians before the aims of the NICE guidelines are met.

Neuromuscular electrical stimulation and the treatment of lower urinary tract dysfunction in multiple sclerosis--a double blind, placebo controlled, randomised clinical trial.

AIMS: Lower urinary tract dysfunction affects up to 75% of the multiple sclerosis population. Results from our recent Pilot Study (McClurg et al., 2006) indicated that a combined programme of pelvic floor muscle training, electromyography biofeedback and neuromuscular electrical stimulation modalities may alleviate some of the distressing symptoms within this population. This clinical trial aimed to evaluate further the efficacy of these interventions and to establish the benefit of neuromuscular electrical stimulation above and beyond that of EMG biofeedback and pelvic floor muscle training. METHODS: 74 multiple sclerosis patients who presented with lower urinary tract dysfunction were randomly allocated to one of two groups - Group 1 received Pelvic Floor Muscle Training, Electromyography Biofeedback and Placebo Neuromuscular Electrical Stimulation (n=37), and Group 2 which received Pelvic Floor Muscle Training, Electromyography Biofeedback, and Active Neuromuscular Electrical Stimulation (n=37). Treatment was for nine weeks with outcome measures recorded at weeks 0, 9, 16 and 24. The Primary Outcome Measure was the number of leakage episodes. Within group analysis was by Paired Samples t-test. Group differences were analysed using Repeated Measures Analysis of Variance and Post-hoc tests were used to determine the significance of differences between Groups at each time point. RESULTS: The mean number of incontinence episodes were reduced in Group 2 by 85% (p=0.001) whereas in Group 1 a lesser reduction of 47% (p=0.001) was observed. However, there was a statistically superior benefit in Group 2 when compared to Group 1 (p=0.0028). This superior benefit was evident in all other outcome measures. CONCLUSIONS: The addition of Active Neuromuscular Electrical Stimulation to a programme of Pelvic Floor Muscle Training and Electromyography Biofeedback should be considered as a first-line option in alleviating some of the symptoms of lower urinary tract dysfunction associated with multiple sclerosis.

Comparison of pelvic floor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: a randomized pilot study.

AIM: Bladder dysfunction affects up to 90% of the multiple sclerosis (MS) population. Interventions such as Pelvic Floor Training and Advice (PFTA), Electromyography (EMG) Biofeedback, and Neuromuscular Electrical Stimulation (NMES) have received limited research attention within this population. This study aimed to determine the effectiveness of a combined programme of PFTA, EMG Biofeedback, and NMES for bladder dysfunction in MS. METHODS: Females (n = 30) who fulfilled strict inclusion/exclusion criteria were recruited. Outcome measures (weeks 0, 9, 16, and 24) included: 3-day Voiding Diary; 24 hr Pad-Test; Uroflowmetry; Pelvic Floor Muscle Assessment; Incontinence Impact Questionnaire (IIQ); Urogenital Distress Inventory (UDI); King's Health Questionnaire (KHQ), and the Multiple Sclerosis Quality of Life-54 Instrument (MSQoL-54). Following baseline (week 0) assessment, participants were randomly allocated, under double blind conditions, to one of the three groups: Group 1 (PFTA); Group 2 (PFTA and EMG Biofeedback); and Group 3 (PFTA, EMG Biofeedback, and NMES). Treatment was for 9 weeks. RESULTS: Baseline severity (measured by number of leaks and pad weight) showed some variation between groups, although not statistically significant (P > 0.05); with the caveat that this baseline imbalance makes interpretation difficult, a picture emerges that at week 9, Group 3 demonstrated superior benefit as measured by the number of leaks and pad test than Group 2, with Group 1 showing less improvement when compared to week 0; this was statistically significant between Groups 1 and 3 for number of leaks (P = 0.014) and pad tests (P = 0.001), and Groups 1 and 2 for pad tests (P = 0.001). A similar pattern was evident for all other outcome measures. CONCLUSION: Results suggest that these treatments, used in combination, may reduce urinary symptoms in MS. Further research will establish the effectiveness of these interventions.