Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study.

OBJECTIVE: To investigate the extent of persistent urinary incontinence (UI) 12 years after birth, and association with delivery-mode history and other factors. DESIGN: Twelve-year longitudinal cohort study. SETTING: Maternity units in Aberdeen, Birmingham, and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over a period of 12 months were obtained from the units and then women were contacted by post. MAIN OUTCOME MEASURE: Persistent UI reported at 12 years, with one or more previous contact. RESULTS: Of 7879 women recruited at 3 months, 3763 (48%) responded at 12 years, with 2944 also having responded at 6 years; non-responders had similar obstetric characteristics. The prevalence of persistent UI was 37.9% (1429/3763). Among those who had reported UI at 3 months, 76.4% reported it at 12 years. Women with persistent UI had lower SF12 quality of life scores. Compared with having only spontaneous vaginal deliveries (SVDs), women who delivered exclusively by caesarean section were less likely to have persistent UI (odds ratio, OR 0.42, 95% CI 0.33-0.54). This was not the case in women who had a combination of caesarean section and SVD births (OR 1.01, 95% CI 0.78-1.30). Older age at first birth, greater parity, and overweight/obesity were associated with persistent UI. Of 54 index primiparae with UI before pregnancy, 46 (85.2%) had persistent UI. CONCLUSIONS: This study, demonstrating that UI persists to 12 years in about three-quarters of women, and that risk was only reduced with caesarean section if women had no other delivery mode, has practice implications. TWEETABLE ABSTRACT: A longitudinal study of 3763 women showed a prevalence of persistent UI 12 years after birth of 37.9%.

Socioeconomic outcomes following spinal cord injury and the role of no-fault compensation: longitudinal study.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To estimate socioeconomic and work outcomes over 2 and a half years following spinal cord injury (SCI), and to compare those in receipt of compensation (Accident Compensation Corporation, ACC) and those not. SETTING: People admitted to the two spinal units in 2007-2009 in New Zealand, where there is a unique no-fault compensation scheme for injury. METHODS: Interviews were conducted at ∼6, 18 and 30 months after SCI and data collected on pre-SCI and post-SCI health and socioeconomic characteristics. Poisson regression, quantile regression and a linear mixed model regression were used to compare differences in outcomes. RESULTS: Of the 162 eligible people, 118 (73%) participated and 91(77%) were followed to 30 months; 79% received ACC. Median personal income, self-reported standard of living and household income adequacy all fell slightly to 18 months and then stabilized at 30 months. At that time, 49% had returned to paid work. Among those not eligible for ACC, income fell to less than half the ACC group (P<0.006 after adjustment), and return to work was lower (29% versus 54%). CONCLUSION: The findings that most people retained their economic status and that return to work was relatively high appear to be due to the proportion entitled to the ACC no-fault compensation scheme for injury; with earnings-related compensation, a focus on rehabilitation to work and non-means-tested support services. This situation should mitigate against the downward spiral into poverty and further ill-health.

Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse.

OBJECTIVES: To investigate prolapse symptoms and objectively measured pelvic organ prolapse, 12 years after childbirth, and association with delivery mode history. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women dwelling in the community. METHODS: Data from women were collected 12 years after an index birth and women were invited for examination. Logistic regression investigated associations between risk factors and prolapse symptoms and signs. MAIN OUTCOME MEASURES: Prolapse symptom score (POP-SS); objectively measured prolapse (POP-Q). RESULTS: Of 7725 continuing women, 3763 (49%) returned questionnaires at 12 years. The median POP-SS score was 2 (IQR 0-4). One or more forceps deliveries (OR 1.20, 95% CI 1.04-1.38) and a body mass index (BMI) over 25 were associated with higher (worse) POP-SS scores, but age over 25 years at first delivery was associated with lower (better) scores. There was no protective effect if all deliveries were by caesarean section (OR 0.84, 95% CI 0.69-1.02). Objective prolapse was found in 182/762 (24%) women. Women aged over 30 years when having their first baby and parity were significantly associated with prolapse. Compared with women whose births were all spontaneous vaginal deliveries, women who had all births by caesarean section were the least likely to have prolapse (OR 0.11, 95% CI 0.03-0.38), and there was a reduced risk after forceps or a mixture of spontaneous vaginal delivery and caesarean section. CONCLUSIONS: These findings are at odds with each other, suggesting that prolapse symptoms and objective prolapse may not be in concordance, or are associated with different antecedent factors. Further follow-up is planned.

Faecal incontinence persisting after childbirth: a 12 year longitudinal study.

OBJECTIVES: To investigate persistent faecal incontinence (FI) 12 years after birth and association with delivery mode history and quality of life. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over 12 months were obtained from units and women were contacted 3 months, 6 years and 12 years post birth. MAIN OUTCOME MEASURE: Persistent FI, defined as reported at 12 years and one or more previous contacts. SF12 assessed quality of life. RESULTS: Of 7879 women recruited at 3 months, 3763 responded at 12 years, 2944 of whom also responded at 6 years: nonresponders were similar in obstetric factors. Prevalence of persistent FI was 6.0% (227/3763); 43% of 12-year responders who reported FI at 3 months also reported it at 12 years. Women with persistent FI had significantly lower SF12 scores. Compared with only spontaneous vaginal deliveries, women who had one or more forceps delivery were more likely to have persistent FI (odds ratio [OR] 2.08, 95% confidence interval [95% CI] 1.53-2.85) but it was no less likely with exclusively caesarean births (OR 0.93, 95% CI 0.54-1.58). More obese women than normal weight women reported persistent FI (OR 1.52, 95% CI 1.06-2.17). CONCLUSIONS: This longitudinal study has demonstrated persistence of FI many years after birth and shown that one forceps birth increased the likelihood, whereas exclusive caesarean birth showed no association. Obesity, which increased symptom likelihood, is a modifiable risk factor.

Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women: an abridged Cochrane systematic review.

Pelvic floor muscle training (PFMT) is a first-line therapy for women with stress, urgency or mixed urinary incontinence (UI). Supervision and content of PFMT programmes is highly variable. The most effective approach to training is not known. The aim of the review was to compare the effects of different approaches to PFMT for women with UI. This was a systematic review with meta-analysis of randomized or quasi-randomized trials in women with stress, urgency or mixed UI that compared one approach to PFMT with another. The Cochrane Incontinence Group Specialised Trials Register (17 May 2011) was searched. Two reviewers independently assessed trials for eligibility and risk of bias, and extracted data. Data were analyzed as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). From 574 records we included 21 trials (1490 women randomized) that addressed 11 comparisons. Comparisons made included: differences in training supervision (amount, individual versus group), in approach (one versus another, the effect of an additional component) and the exercise training (type of contraction, frequency of training). There were few trials or data in any comparison. In women with stress UI, 10% who received more health professional contact (weekly or twice-weekly group supervision plus individual appointments) did not report improvement compared to 43% who had individual appointments only (risk ratio for no improvement 0.29, 95% confidence interval 0.15 to 0.55, four trials). While women receiving more contact were more likely to report improvement, the confidence interval was wide, and more than half of "controls" reported improvement. This finding, of subjective improvement in both active treatment groups, with more improvement reported by those receiving more health professional contact, was consistent throughout the review. Considerable caution is needed in interpreting the results of the review. Existing evidence is insufficient to make any strong recommendations about the best approach to PFMT. A consistent pattern of more self-reported improvement with more health professional contact was observed; the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing PFMT with little or no supervision. The clinical rehabilitation impact is to offer women reasonably frequent health professional contact during supervised PFMT.

Reliability and diagnostic characteristics of clinical tests of upper limb motor function.

There is a paucity of information on the inter-rater reliability and predictive value of components of the neurological examination. Selected tests of upper limb motor function were studied in 34 patients with Parkinson's disease, upper motor neuron disease or cerebellar disease and in 25 control participants. Video recordings were independently evaluated and scored by two clinicians to determine inter-rater reliability (kappa) and predictive values. Kappa values ranged from 0.00 to 0.73. Highest positive predictive values (PPV) were obtained for the Barré test, arm raise, forearm rolling and finger nose tests. Negative predictive values (NPV) were mostly low, with highest values for unimanual sequential finger tap and rhythmic tap. The combined tests had PPV of 0.58 and NPV of 0.73. This study demonstrates that these clinical tests have poor inter-rater reliability and low negative predictive value when used in isolation.

Time-frequency analysis of chewing activity in the natural environment.

UNLABELLED: The aim of this observational study was to investigate the features of the chewing activity and the variability of the human chewing pace, as assessed in the natural environment. It was hypothesized that the chewing pace is relatively constant within individuals across different days but is variable across individuals. Electromyographic surface activity was recorded unilaterally from the masseter in 21 participants for 3 hours over 3 recording days, in the natural environment, by means of portable recorders. The time-frequency properties of chewing activity were assessed with a previously validated algorithm. Repeated-measurements ANOVA was used for statistical analysis. Chewing activity mainly occurred in the range of 0.94 Hz (5(th) percentile) and 2.17 Hz (95(th) percentile). Mean and median chewing frequencies were 1.57 Hz and 1.58 Hz, respectively (95% confidence intervals: 1.45-1.68 Hz). The mean duration of chewing episodes was 13.0 sec, the 5(th) and 95(th) percentiles being 2.7 sec and 34.9 sec, respectively. Variability of the mean chewing frequency between individuals was much greater than that within individuals (F = 29.8; p < 0.001). The individual chewing paces were stable across different days (intraclass correlation coefficient = 0.88; 95% confidence intervals = 0.79-0.94). Our findings provide evidence that each individual, in the natural environment, chews with a consistent pace across different days. ABBREVIATIONS: ANOVA, analysis of variance; CPG, central pattern generator; EMG, electromyography; ICC, Intra-class Correlation coefficient; SD, standard deviation.

Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study.

OBJECTIVES: To investigate the association between delivery mode history and urinary and faecal incontinence, specifically a history of exclusive caesarean section deliveries. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women who returned postal questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over a 12-month period were obtained from units and women were followed 3 months, 6 years and 12 years after the birth. MAIN OUTCOME MEASURES: Urinary incontinence (UI) and faecal incontinence (FI) 12 years after index birth. RESULTS: Of the 7883 women recruited at 3 months, 3763 were followed up at 12 years: nonresponders were similar in their obstetric factors. After adjustment for parity, body mass index and age at first birth, women who delivered exclusively by caesarean section were less likely to have UI than those who only had spontaneous vaginal births (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.37-0.58), but not if they had a combination of caesarean and spontaneous vaginal births (OR 1.14, 95% CI 0.89-1.47). There was no difference in FI among women who had exclusive caesarean births (OR 0.94, 95% CI 0.66-1.33) or mixed caesarean and spontaneous vaginal births (OR 1.06, 95% CI 0.73-1.54). CONCLUSIONS: Unless women are resolved to have all their deliveries by the abdominal route (and their medical advisors agree), caesarean section does not protect from subsequent UI. Even among those who do deliver exclusively by caesarean section, 40% still report UI; and this strategy confers no benefit for subsequent FI.

Aspirin resistance determined from a bed-side test in patients suspected to have acute coronary syndrome portends a worse 6 months outcome.

BACKGROUND: Coronary patients resistant to aspirin may have increased risk for ischemic events. Little data were available for patients presenting acutely with chest pain. METHODS AND RESULTS: We used the VerifyNow Aspirin to determine aspirin responsiveness of 314 patients regularly taking aspirin 75-300 mg daily for >or=4 weeks who presented with suspected acute coronary syndrome in Emergency Department. Aspirin resistance was defined as an aspirin reaction unit (ARU) >or=550, and the clinical team was blinded to the ARU reading. The pre-specified study endpoints were the diagnosis of acute myocardial infarction (AMI) for the index admission and major adverse cardiac events including cardiovascular death or recurrent acute coronary syndrome requiring hospitalization within 6 months. Aspirin resistance was noted in 30 (9.6%) patients. There was no difference in the diagnosis of AMI for the index presentation (3/30, 10% vs. 25/284, 8.8%, P = 0.91). Among the 312 hospital survivors, aspirin resistant patients had increased adverse events over 6 months with an overall hazard ratio of 10.0 [95% confidence interval (CI) 4.6-22.0]. After adjusted for elevated Troponin-T, the only confounder in the model, the hazard ratio was 11.1 (95% CI 4.7-26.0). Results were similar in patients treated only medically without revascularization (adjusted hazard ratio 12.1, 95% CI 4.7-26.4). The increased events were observed both from discharge to 30 days and from 30 days to 6 months. CONCLUSION: Aspirin resistance occurs in approximately 10% of patients presenting with suspected acute coronary syndrome and is associated with adverse cardiac events.

Osteoporosis and gait and balance disturbances in older sarcopenic obese New Zealanders.

UNLABELLED: Bone, muscle, and fat may affect gait and balance in older adults. Osteoporosis was prevalent in low muscle mass participants and related to gait and balance deficits. Low muscle combined with high fat mass had more functional deficits and poorer bone health, which has implications for falls risk and fractures. INTRODUCTION: Decreasing bone density and muscle mass and increasing fat mass may act synergistically to affect gait and balance in older adults. METHODS: One hundred eighty-three older adults (age 72.7 +/- 6 years, range 56-93; body mass index 28.2 +/- 4.9, range 16.6-46.0) were recruited from a New Zealand falls prevention intervention trial. Total and appendicular skeletal muscle mass (ASM), percent fat, and bone mineralization were assessed by dual energy X-ray absorptiometry and used to characterize normal lean (NL, n = 51), sarcopenic (SS, n = 18), sarcopenic obese (SO, n = 29), and obese (OO, n = 85) phenotypes. Functional performance was assessed using timed up and go, chair stand, single leg stand, and step test. Regression models were adjusted for age, sex, medications, and physical activity. RESULTS: Femoral neck osteoporosis was present in 22% SS, 17% SO, 12% NL, and 7% OO. Femoral neck osteoporosis with low ASM predicted poor chair stand performance (beta -3.3, standard error 1.6, p = 0.04). SO scored lowest on the chair stand (p = 0.03) and step test (p = 0.03). Higher ASM predicted faster timed up and go performance (p = 0.001). CONCLUSIONS: Osteoporosis was prevalent in low ASM groups (SS and SO) and related to gait and balance deficits, particularly in the SO. This has implications for falls risk, fractures, and interventions.

Research priorities in urinary incontinence: results from citizens' juries.

OBJECTIVE: The objective of this study was to elicit research ideas, priorities and outcome measures from women who suffer from urinary incontinence. DESIGN: Citizens' juries gather participants together for a combination of education and deliberation on a specific topic. The juries were held in November 2007. SETTING: Women living in the community with urinary incontinence. SAMPLE: Purposively selected responders to public advertisements in Dunedin, New Zealand, were grouped into two juries dependent on whether stress urinary incontinence or urge urinary incontinence was the predominant problem. METHODS: The juries had a day of education in incontinence and research-related issues, with a half day for deliberation and reporting. MAIN OUTCOME MEASURES: Ideas for areas where research may help the lives of women with incontinence in priority order and how best to measure the outcome of that research. RESULTS: The juries identified five main areas for incontinence research with only minor differences depending on which jury. These are, in priority order, making seeking help easier, making day-to-day life more manageable, finding out total costs, more knowledge about causes and the effects of lifestyle. Quality of life was considered by far the most important outcome. CONCLUSIONS: Citizens' juries are able to come up with ideas for research and prioritise these. Research in the areas suggested would be likely to improve the lives of women with urinary incontinence and may lead to a different mix of research projects than is currently the case.

The false and the true bifid condyles.

The bifid mandibular condyle has been described as a condition of unknown aetiology and uncertain pathogenesis. Many see it as the product of accidental trauma or forceps delivery, with the two heads occurring one behind the other in the sagittal plane. In bioanthropological literature, "bifid condyle" often describes pitting in the sagittal plane, dividing the condyle mediolaterally. We examined 38 male and 16 female pre-European-contact Pacific islanders' adult mandibles, and 24 male and 29 female modern Indian mandibles, recording frequency, prominence and position of any condylar groove in both coronal and sagittal planes. We report the tenth known case of a bilaterally-bifid condyle. A groove was found almost twice as likely to occur on the left condyle of the Indians than of the Pacific Islanders, but equally likely to occur on the right side of both groups. That same finding applied to males and females. In order to avoid terminological ambiguity, we suggest that the term "bifid condyle" should be reserved for describing multiple condyles in the sagittal plane only - the true bifid condyle. An hypothesis is offered for the occurrence of the groove in the sagittal plane.

Interventions for relieving the pain and discomfort of screening mammography.

BACKGROUND: The pain of mammography is recognised as a significant deterrent for women considering this examination, and may affect participation in breast screening. OBJECTIVES: To review interventions to reduce or relieve the pain and discomfort of screening mammography. SEARCH STRATEGY: For this update, the Cochrane Breast Cancer Group Specialised Register was searched on the 18th May 2006. Other databases searched were MEDLINE (1966 to November 2006), CINAHL (1982 to December 2006), EMBASE (1988 to 2006) and reference lists of articles. We also searched Current Controlled Trials (www.controlled-trials.com, accessed September 2007) and the UK National Research Register (www.update-software.com/national/, accessed September 2007) for ongoing and completed research projects. Researchers in the field were also contacted. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials with a comparison group were considered. Studies had to include assessment of pain or discomfort and, if the intervention could have impacted on the quality of the mammograms, an assessment of image quality was also required. DATA COLLECTION AND ANALYSIS: Two authors (DM and VL) reviewed identified studies to determine whether they met the inclusion criteria. Each study was reviewed for quality, including concealment and generation of allocation sequence, comparability between groups at baseline, inclusion of all randomised participants in analysis and blinding after allocation. Data extraction was performed by these two authors. MAIN RESULTS: Seven RCTs, involving 1671 women were identified for inclusion. The review found that giving women information about the procedure prior to the mammogram may reduce pain and discomfort. Increasing women's control over breast compression could reduce pain experienced during the procedure, though mammogram image quality was only maintained if the technologist controlled the first compression. If the technologist reduced compression force of the mammogram, discomfort experienced was unchanged. The use of breast cushions reduced pain of mammography; however, image quality was impaired in 2% of women in the intervention group. Acetoaminophen as a premedication did not affect discomfort of mammography. Differences in interventions, and inconsistency in measures, validation of pain scales, and in assessment of mammogram quality, mean that results of these studies cannot be combined. All results are based on single studies. Further research is required. AUTHORS' CONCLUSIONS: Currently there are very few proven interventions to reduce pain and discomfort of screening mammography, especially procedures that can be readily introduced to screening programmes. With mammography continuing as the preferred method for breast screening, more research on such interventions is needed.

Pre-existent depression in the 2 weeks before an acute coronary syndrome can be associated with delayed presentation of the heart attack.

BACKGROUND: Depression is common among patients with acute coronary syndrome (ACS). AIM: To examine how depression may alter outcome of ACS. DESIGN: Observational study on how ongoing depression influences the time delay to seeking help and its effects on subsequent treatment compliance after discharge. METHODS: Depression was measured by Beck Depression Inventory (BDI) 2 weeks prior to presentation on consecutive patients with ACS. RESULTS: Of the 276 patients, 81 had BDI > or =10 and 195 had BDI score <10. The time from onset of the predominant symptom to seeking help tended to be longer in those with BDI > or =10 than in those with BDI <10 [180 (IQR 37.5-1042.5) min vs. 120 (IQR 30-735) min, P = 0.099]. Results were similar for the 68 with ST elevation myocardial infarction (MI) [238 (IQR 49-709) min vs. 60 (IQR 20-352) min, P = 0.071]. Each point increase of BDI predicted an approximately 4.2% [95% confidence interval (CI) 0.4-8.0%] increase in the time duration, P = 0.029. On multivariable analysis, the effect of BDI persisted (6.0% increase in duration per each point increase in BDI, 95% CI 2.4-9.7%, P = 0.001). Among the 68 patients who had ST elevation MI, results were similar with an 8.0% (95%CI 1.7-14.7%, P = 0.013) increase in time duration for each unit increase in BDI. Results were also similar when BDI was evaluated as a dichotomous variable. Small differences were observed for subsequent treatment compliance. CONCLUSION: Ongoing depression delays the presentation of ACS.

WITHDRAWN: Physical therapies for prevention of urinary and faecal incontinence in adults.

BACKGROUND: Physical therapies, particularly pelvic floor muscle training, have been recommended for prevention of incontinence associated with childbearing, and prostate surgery. OBJECTIVES: To assess the effectiveness of physical therapies in preventing incontinence in adults. SEARCH STRATEGY: The Cochrane Incontinence Group trials register was searched to September 2001. Trials were also sought from the Reference Lists of relevant articles and from experts in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials in adults without incontinence symptoms that compared a physical therapy with no treatment, or any other treatment to prevent incontinence. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook. MAIN RESULTS: Two trials in men (155 men) and 13 trials in women (4661 women) were included. As most trials recruited regardless of continence status, and there was much heterogeneity, only a qualitative synthesis was undertaken. Three of seven trials in childbearing women reported less urinary incontinence after pelvic floor muscle training compared to control treatment three months postpartum. Two trials selected women at higher risk of postnatal incontinence. The third used an intensive training programme. Four trials did not find any difference between the groups at the primary endpoint. Two trials compared pre-prostate surgery pelvic floor muscle training with control treatment, and no difference in the occurrence of postoperative urinary incontinence was reported between the groups. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine whether physical therapies can prevent incontinence in childbearing women, or men following prostate surgery. Further, better quality research is needed.

Risk of herpes simplex virus type 2 acquisition increases over early adulthood: evidence from a cohort study.

UNLABELLED: DESIGN/ SETTING: A cohort study of 1037 people born in Dunedin, New Zealand, in 1972 or 1973. PARTICIPANTS: At assessment at age 32 years, 884 participants (432 women and 452 men; 87.1% of the surviving cohort) provided both sera and information on sexual behaviour. MAIN OUTCOME MEASURES: The proportion of participants with antibodies to HSV-2 infection at ages 26 and 32 years was measured, and the incidence rates from first coitus to age 26 years and from age 26 to 32 years calculated, adjusting for the number of sexual partners and same-sex contact in these age periods. RESULTS: At age 32 years, 14.6% of men and 22.5% of women had antibodies to HSV-2. The incidence rates for men and women from first coitus to age 26 years were, respectively, 6.5 and 14.3 per 1000 person-years. The incidence rates for men and women from age 26-32 years, respectively, were 14.3 and 15.8 per 1000 person-years. When adjusted for sexual behaviour, the incidence rate ratio, comparing the older with the younger age periods, was 2.9 (95% confidence interval (CI) 1.7 to 4.9) for men and 2.0 (1.2 to 3.4) for women. The adjusted incidence rate ratio when comparing women to men from first coitus to age 26 years was 2.5 (1.6 to 4.0), and from age 26-32 years was 1.3 (0.78 to 2.2). A test for interaction indicated that men and women had different patterns of incidence over time (p = 0.039). CONCLUSION: In the general population, the risk of acquiring HSV-2 infection seems to increase with age at least to the early 30s, and differences in risk of acquisition for women compared with men become less with age. Health promotion and treatment to control HSV-2 infection should be aimed at all ages, not just at the young.

Laparoscopic colposuspension and tension-free vaginal tape: a systematic review.

BACKGROUND: Advances in surgical techniques have led to the availability of a number of minimal-access procedures to treat urodynamic stress incontinence (USI). These procedures have been individually compared with the 'gold standard' open Burch colposuspension; however, it now seems appropriate to compare like with like and compare these minimal-access techniques with each other. OBJECTIVES: To determine the effectiveness of laparoscopic colposuspension with tension-free vaginal tape (TVT) for the treatment of USI. SEARCH STRATEGY: Randomised trials in woman with USI, which compared laparoscopic colposuspension with TVT in the arms of the trial, were identified from the Cochrane Incontinence Review Group's Specialised Register of Controlled Trials. SELECTION CRITERIA: The trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers using the Incontinence Group's assessment criteria. DATA COLLECTION AND ANALYSIS: The data were extracted independently, and when appropriate, meta-analysis was undertaken to calculate pooled estimates and their confidence intervals (CI). The main outcomes measured were: subjective cure, objective cure, quality of life (QoL) measurements, surgical outcomes and health economic measures. MAIN RESULTS: Seven trials compare laparoscopic colposuspension (n= 264) with TVT (n= 290). There was no statistically significant difference in the reported subjective cure rate between laparoscopic colposuspension and TVT within 18 months (relative risk [RR] 1.12, 95% CI 0.98-1.29). However, within the same time period, the overall objective cure rate was statistically significantly higher for TVT (RR 1.16, 95% CI 1.07-1.25). There were no significant differences between the two procedures with regards to perioperative complication, de novo detrusor overactivity, voiding dysfunction, procedural costs and QoL scores. However, TVT procedure is quicker to perform and has a shorter hospital stay. CONCLUSIONS The evidence so far appears to be in favour of the TVT as the minimal-access technique of choice for USI in comparison with laparosopic colposuspension; however, long-tem data are needed. Further well-designed trials with standardized outcomes are required to draw accurate conclusions from this comparison.

Anticholinergic drugs versus placebo for overactive bladder syndrome in adults.

BACKGROUND: Around 16% of adults have symptoms of overactive bladder (urgency with frequency and/or urge incontinence). The prevalence increases with age. Anticholinergic drugs are commonly used to treat this condition. OBJECTIVES: To determine the effects of anticholinergic drugs for the treatment of overactive bladder syndrome. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 14 June 2005) and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug with placebo treatment or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewer authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005). MAIN RESULTS: Sixty -one trials, 42 with parallel-group designs and 19 crossover trials were included (11,956 adults). Most trials were described as double-blind but were variable in other aspects of quality. The crossover trials did not present data in a way that allowed inclusion in the meta-analysis. Nine medications were tested: darifenacin; emepronium bromide or carrageenate; oxybutynin; propiverine; propantheline; tolterodine; trospium chloride; and solifenacin. One trial included the newer, slow release formulation of tolterodine. At the end of the treatment period, cure or improvement (relative risk (RR) 1.39, 95% CI 1.28 to 1.51), difference in leakage episodes in 24 hours (weighted mean difference (WMD) -0.54; 95% CI -0.67 to -0.41) and difference in number of voids in 24 hours (WMD -0.69; 95% CI -0.84 to -0.54) were statistically significant favouring medication. Statistically significant but modest sized improvements in quality of life scores were reported in recently completed trials. There was three times the rate of dry mouth in the medication group (RR 3.00 95% CI 2.70 to 3.34) but no statistically significant difference in withdrawal (RR 1.11, 95% CI 0.91 to 1.36). Sensitivity analysis, while limited by small numbers of trials, showed little likelihood that the effects were modified by age, sex, diagnosis, or choice of drug. AUTHORS' CONCLUSIONS: The use of anticholinergic drugs by people with overactive bladder syndrome results in statistically significant improvements in symptoms. Recent trials suggest that this is associated with modest improvement in quality of life. Dry mouth is a common side effect of therapy but did not seem to have an effect on the numbers of withdrawals. It is not clear whether any benefits are sustained during long-term treatment or after treatment stops.

The influence of context on students' approaches to learning: a case study.

This paper gives an account of a small-scale longitudinal study that examined changes in conceptions and approaches to learning as 14 students experience a problem-based learning (PBL) curriculum for the first time. The course in oral biology aimed to encourage conceptual understanding of the topic and improve student learning through its PBL curriculum and assessment method. Those who entered the course with a surface approach and fragmented conception of learning left with a deep-learning approach, cohesive conception and quality learning outcomes. There were no observable changes in the students who started the course with a deep-learning approach and cohesive conception, except for two who reported surface approaches and fragmented conceptions at the end. These two students also achieved the lowest examination scores. To help explain these findings we examine the wider context for student learning including student motivation.

Which anticholinergic drug for overactive bladder symptoms in adults.

BACKGROUND: Around 16% to 45% of adults have overactive bladder symptoms (urgency with frequency and/or urge incontinence - 'overactive bladder syndrome'). Anticholinergic drugs are common treatments. OBJECTIVES: To compare the effects of different anticholinergic drugs for overactive bladder symptoms. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised trials register (searched 17 January 2002) and reference lists of relevant articles. A search for full publications of abstracts identified in January 2002 was completed in July 2003. SELECTION CRITERIA: Randomised trials in adults with overactive bladder symptoms or detrusor overactivity that compared one anticholinergic drug with another, or two doses of the same drug. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook. MAIN RESULTS: Forty nine trials, 39 parallel and 10 cross-over designs were included (11,332 adults). Most trials were described as double-blind, but were variable in other aspects of quality. Crossover studies did not present data in a way that could be included in the meta-analysis.Four trials collected quality of life data (the primary outcome measure) using validated measures; none reported useable data. Oxybutynin versus tolterodine: There were no statistically significant differences for patient perceive improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events (RR 0.57, 95% CI 0.43 to 0.75), and less risk of dry mouth (RR 0.60, 95% CI 0.54 to 0.66), with tolterodine. Different doses tolterodine: The usual recommended starting dose (2 mg twice daily) was compared with two lower (0.5 mg and 1 mg twice daily), and one higher dose (4 mg twice daily). The effect of 1 mg, 2 mg and 4 mg doses was similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses.Extended versus immediate release preparations of oxybutynin and/or tolterodine: There were no statistically significant differences for cure/improvement, leakage episodes or micturitions in 24 hours, or withdrawals due to adverse events, but there were few data. Overall, extended release preparations had less risk of dry mouth. One extended release preparation versus another: There was less risk of dry mouth with oral extended release tolterodine than oxybutynin (RR 0.75, 95% CI 0.59 to 0.95), but no difference between transdermal oxybutynin and oral extended release tolterodine although some people withdrew due to skin reaction at the trandermal patch site. AUTHORS' CONCLUSIONS: Where the prescribing choice is between oral immediate release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. With tolterodine, 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth. There is little or no evidence available about quality of life, costs, or long-term outcome in these studies. There were insufficient data from trials of other anticholinergic drugs to draw any conclusions.