Washout policies in long-term indwelling urinary catheterisation in adults

Background  People requiring long-term bladder draining with an indwelling catheter can experience catheter blockage. Regimens involving different solutions can be used to wash out catheters with the aim of preventing blockage. This is an update of a review published in 2010.  Objectives  To determine if certain washout regimens are better than others in terms of effectiveness, acceptability, complications, quality of life and critically appraise and summarise economic evidence for the management of long-term indwelling urinary catheterisation 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 to 23 May 2016. We also examined all reference lists of identified trials and contacted manufacturers and researchers in the field.  Selection criteria  All randomised and quasi-randomised trials comparing catheter washout policies (e.g. washout versus no washout, different washout solutions, frequency, duration, volume, concentration, method of administration) in adults (aged 16 years and above) in any setting (i.e. hospital, nursing/residential home, community) with an indwelling urethral or suprapubic catheter for more than 28 days.  Data collection and analysis  Two review authors independently extracted data. Disagreements were resolved by discussion. Data were assessed and analysed as described in theCochrane Handbook. If data in trials were not fully reported, clarification was sought from the study authors. For categorical outcomes, the numbers reporting an outcome were related to the numbers at risk in each group to derive a risk ratio (RR). For continuous outcomes, means and standard deviations were used to derive mean differences (MD).  Main results  We included seven trials involving a total of 349 participants, 217 of whom completed the studies. Three were cross-over and four were parallel-group randomised controlled trials (RCTs). Of these, two trials were added for this update (one parallel-group RCT with 40 participants and one cross-over RCT with 67 participants). Analyses of three cross-over trials yielded suboptimal results because they were based on between-group differences rather than individual participants' differences for sequential interventions. Two parallel-group trials had limited clinical value: one combined results for suprapubic and urethral catheters and the other provided data for only four participants. Only one trial was free of significant methodological limitations, but there were difficulties with recruitment and maintaining participants in this study.  The included studies reported data on six of the nine primary and secondary outcome measures. None of the trials addressed: number of catheters used, washout acceptability measures (including patient satisfaction, patient discomfort, pain and ease of use), or health status/measures of psychological health; very limited data were collected for health economic outcomes. Trials assessed only three of the eight intervention comparisons identified. Two trials reported in more than one comparison group.  Four trials compared washout (either saline or acidic solution) with no washout. We are uncertain if washout solutions (saline or acidic), compared to no washout solutions, has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.  Four trials compared different types of washout solution; saline versus acidic solutions (2 trials); saline versus acidic solution versus antibiotic solution (1 trial); saline versus antimicrobial solution (1 trial). We are uncertain if type of washout solution has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.  One trial compared different compositions of acidic solution (stronger versus weaker solution). We are uncertain if different compositions of acidic solutions has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because only 14 participants (of 25 who were recruited) completed this 12 week, three arm trial.  Four studies reported on possible harmful effects of washout use, such as blood in the washout solution, changes in blood pressure and bladder spasms.  There were very few small trials that met the review inclusion criteria. The high risk of bias of the included studies resulted in the evidence being graded as low or very low quality.  Authors' conclusions  Data from seven trials that compared different washout policies were limited, and generally, of poor methodological quality or were poorly reported. The evidence was not adequate to conclude if washouts were beneficial or harmful. Further rigorous, high quality trials that are adequately powered to detect benefits from washout being performed as opposed to no washout are needed. Trials comparing different washout solutions, washout volumes, and frequencies or timings are also needed

An overview of urinary incontinence

Urinary incontinence is a common problem that is often under-reported due to the embarrassing nature and social stigma attached. Urinary incontinence can have a considerable effect on an individual’s quality of life, but can be significantly improved with correct assessment, treatment and management. Conservative treatment options including: pelvic floor exercises, bladder retraining and fluid modification are recommended before referral to secondary services. This article provides an overview of the main types of urinary incontinence, and summarises recent guidelines for the assessment, diagnosis and effective conservative treatment options for them and when a referral for specialist care is required

The Role of Public Opinion in the Regulation of Genomics in the United Kingdom

This thesis analyses the role played by public opinion in the regulation of genomics, and conversely the role that regulation plays in shaping public opinion. It is argued that there has been an over-emphasis on the use of public opinion by regulators, and that this is a rhetorical strategy. There are strong normative drivers behind the regulation of genomics, which include the argument that regulation has the capacity to imbue public confidence in novel technologies and that enhanced deliberation will help to placate public concerns. While not dismissing these arguments, the thesis shows that in practice the interaction between regulation and public opinion is not so clear. It is argued that both regulation per se and the very existence and visible presence of independent regulatory agencies overseeing genomics can help to alleviate public concern. A key finding is that although regulators refer to public opinion, in practice they actually respond to stakeholder opinion. The thesis analyses the classic interpretation of public opinion, survey data, and contrasts it with regulators’ understandings of public opinion and with public opinion data collected by independent regulatory agencies. The regulators interviewed agree that the public opinion data used in the regulatory process is not representative of public opinion. However, public opinion is still used as a way of legitimating policy. It is for this reason that I suggest ‘public opinion’ should, for reasons of transparency, be called ‘public opinion data’. Such a move would reflect its value in the regulatory process, but equally indicate that such data has inherent limitations. The argument is supported by evidence from two case-studies from genomics, both of which are significant areas of scientific and public concern. The first is prenatal testing and preimplantation genetic diagnosis (PGD) and the second is Genetically Modified foods. The thesis questions whether the sui generis features of genomics merit its special regulatory handling and the enhanced role given to public opinion in this area

Development of a phage cocktail to control Proteus mirabilis catheter-associated urinary tract infections

"Article 1024"Proteus mirabilis is an enterobacterium that causes catheter-associated urinary tract infections (CAUTIs) due to its ability to colonize and form crystalline biofilms on the catheters surface. CAUTIs are very difficult to treat, since biofilm structures are highly tolerant to antibiotics. Phages have been used widely to control a diversity of bacterial species, however a limited number of phages for P. mirabilis have been isolated and studied. Here we report the isolation of two novel virulent phages, the podovirus vB_PmiP_5460 and the myovirus vB_PmiM_5461, which are able to target respectively, 16 of the 26 and all the Proteus strains tested in this study. Both phages have been characterized thoroughly and sequencing data revealed no traces of genes associated with lysogeny. To further evaluate the phages ability to prevent catheter´s colonization by Proteus, the phages adherence to silicone surfaces was assessed. Further tests in phage-coated catheters using a dynamic biofilm model simulating CAUTIs, have shown a significant reduction of P. mirabilis biofilm formation up to 168 h of catheterization. These results highlight the potential usefulness of the two isolated phages for the prevention of surface colonization by this bacterium.This study was supported by the Portuguese Foundation for Science and Technology (FCT) under the scope of the strategic funding of UID/BIO/04469/2013 unit, COMPETE 2020 (POCI- 01-0145-FEDER-006684) and by the Portuguese Foundation for Science and Technology (FCT) under the scope of the Project RECI/BBB-EBI/0179/2012 (FCOMP-01-0124-FEDER- 027462). NC and SS also thank FCT for the individual support through Investigador FCT contracts

Encrusted and incarcerated urinary bladder catheter: what are the options?

Urinary bladder catheter encrustations are known complications of long-term urinary catheterisation, which is commonly seen in clinical practice. These encrustations can impede deflation of the balloon and therefore cause problems in the removal of the catheter. The options in managing an encrusted and incarcerated urinary bladder catheter include extracorporeal shock wave lithotripsy and lithoclast. We describe here another technique of dealing with a stuck and encrustated catheter, via direct crushing of the encrustations with a rigid cystoscope inserted through a suprapubic cystostomy tract