[Practice guideline 'Urinary incontinence in women' from the Dutch College of General Practitioners]. / NHG-standaard 'Incontinentie voor urine bij vrouwen'.

- The Dutch College of General Practitioners' (NHG) practice guideline 'Urinary incontinence in women' provides guidelines for diagnosis and management of stress, urgency and mixed urinary incontinence in adult women.- General practitioners (GPs) should be alert to signals for urinary incontinence in women and offer active diagnosis and treatment if necessary.- Shared decision making is central in the guideline; the GP and the patient should discuss therapeutic options and decide on treatment policy in mutual consultation.- Women with stress urinary incontinence can choose between pelvic floor exercises or a pessary as initial treatment. Placing a midurethral sling (MUS) will be discussed if initial treatment is insufficiently effective or in the case of serious symptoms.- When bladder training is ineffective in urgency incontinence, the GP will discuss the pros and cons of adding an anticholinergic agent.- Exercise therapy can take place in the GPs practice or under supervision of a pelvic physical therapist.

Predicting who will undergo surgery after physiotherapy for female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: To predict who will undergo midurethral sling surgery (surgery) after initial pelvic floor muscle training (physiotherapy) for stress urinary incontinence in women. METHODS: This was a cohort study including women with moderate to severe stress incontinence who were allocated to the physiotherapy arm from a previously reported multicentre trial comparing initial surgery or initial physiotherapy in treating stress urinary incontinence. Crossover to surgery was allowed. RESULTS: Data from 198/230 women who were randomized to physiotherapy was available for analysis, of whom 97/198 (49 %) crossed over to surgery. Prognostic factors for undergoing surgery after physiotherapy were age <55 years at baseline (OR 2.87; 95 % CI 1.30-6.32), higher educational level (OR 3.28; 95 % CI 0.80-13.47), severe incontinence at baseline according to the Sandvik index (OR 1.77; 95 % CI 0.95-3.29) and Urogenital Distress Inventory; incontinence domain score (OR 1.03; per point; 95 % CI 1.01-1.65). Furthermore, there was interaction between age <55 years and higher educational level (OR 0.09; 95 % CI 0.02-0.46). Using these variables we constructed a prediction rule to estimate the risk of surgery after initial physiotherapy. CONCLUSION: In women with moderate to severe stress incontinence, individual prediction for surgery after initial physiotherapy is possible, thus enabling shared decision making for the choice between initial conservative or invasive management of stress urinary incontinence.

Dutch evidence statement for pelvic physical therapy in patients with anal incontinence.

INTRODUCTION AND HYPOTHESIS: To promote agreement among and support the quality of pelvic physiotherapists' skills and clinical reasoning in The Netherlands, an Evidence Statement Anal Incontinence (AI) was developed based on the practice-driven problem definitions outlined. We present a summary of the current state of knowledge and formulate recommendations for a methodical assessment and treatment for patients with AI, and place the evidence in a broader perspective of current developments. METHODS: Electronic literature searches were conducted in relevant databases with regard to prevalence, incidence, costs, etiological and prognostic factors, predictors of response to therapy, prevention, assessment, and treatment. The recommendations have been formulated on the basis of scientific evidence and where no evidence was available, recommendations were consensus-based. RESULTS: The evidence statement incorporates a practice statement with corresponding notes that clarify the recommendations, and accompanying flowcharts, describing the steps and recommendations with regard to the diagnostic and therapeutic process. The diagnostic process consists of history-taking and physical examination supported by measurement instruments. For each problem category for patients with AI, a certain treatment plan can be distinguished dependent on the presence of pelvic floor dysfunction, awareness of loss of stools, comorbidity, neurological problems, adequate anorectal sensation, and (in)voluntary control. Available evidence and expert opinion support the use of education, pelvic floor muscle training, biofeedback, and electrostimulation in selected patients. CONCLUSIONS: The evidence statement reflects the current state of knowledge for a methodical and systematic physical therapeutic assessment and treatment for patients with AI.

[Analysis of health policies to prevent non communicable diseases in the Wallonie-Brussels Federation]. / Analyse des politiques de prévention des maladies non transmissibles dans la Fédération Wallonie-Bruxelles.

Because of their high prevalence and constant increase, and their impact in terms of human and financial costs, non-communicable diseases (NCD) represent an important public health issue. Recognizing this alarming situation, the international Community took decisive commitments to reduce the spread of this epidemic of the 21st century. These commitments have been translated in the national prevention and care policies. In the Wallonie-Brussels Federation (WBF), a set of health policies to prevent non communicable diseases was initiated. The objectives of the study were to describe, explore promotion and primary and secondary prevention against NCDs policies in WBF, to highlight the main challenges and issues, and to provide some recommendations to concerned actors. To achieve the objectives of this study, a literature review and a qualitative approach were used. Semi-structured interviews of key stakeholders were conducted in WBF. It involved 14 actors selected for their involvement in the formulation and implementation of these policies. It appears that the Belgian institutional complexity, the lack of willingness of policymakers in prevention and health promotion, the lack of a comprehensive structured policy of prevention and health promotion and an absence of any coordination structure are the main obstacles facing the formulation and implementation of these policies.

Responsiveness and interpretability of incontinence severity scores and FIQL in patients with fecal incontinence: a secondary analysis from a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: This study aims to assess the responsiveness and interpretability of the Vaizey score, Wexner score, and the Fecal Incontinence Quality of Life Scale (FIQL) for use in the evaluation of patients with fecal incontinence (FI). METHODS: Eighty patients with FI with a mean age of 59.3 (SD ± 11.9) were enrolled in a randomized controlled trial. The patient-reported outcomes were tested for internal and external responsiveness, longitudinal construct validity, and interpretability. RESULTS: All total scores proved to have both adequate to excellent responsiveness and longitudinal construct validity, and changes were in agreement with subjective improvement. Due to variability in minimally important change estimates (Vaizey score -5 to -3, Wexner score -3 to -2, FIQL 1.1 to 1.2), they should be used as indicators. All patient-reported outcomes showed psychometric or practical limitations. CONCLUSIONS: The instruments available to date to evaluate severity and quality of life in FI do not yet attain the highest levels of psychometric soundness. As the focus of patients may differ from that of physicians, it is recommended that several measures should be included for evaluation. So far, there are suggestions that the Wexner score is most suitable for severity assessment and the FIQL for evaluating quality of life.

Cost-effectiveness of involving nurse specialists for adult patients with urinary incontinence in primary care compared to care-as-usual: an economic evaluation alongside a pragmatic randomized controlled trial.

AIMS: To determine the 12-month, societal cost-effectiveness of involving urinary incontinence (UI) nurse specialists in primary care compared to care-as-usual by general practitioners (GPs). METHODS: From 2005 until 2008 an economic evaluation was performed alongside a pragmatic multicenter randomized controlled trial comparing UI patients receiving care by nurse specialists with patients receiving care-as-usual by GPs in the Netherlands. One hundred eighty-six adult patients with stress, urgency, or mixed UI were randomly allocated to the intervention and 198 to care-as-usual; they were followed for 1 year. Main outcome measures were Quality Adjusted Life Year (QALY(societal) ) based on societal preferences for health outcomes (EuroQol-5D), QALY(patient) based on patient preferences for health outcomes (EuroQol VAS), and Incontinence Severity weighted Life Year (ISLY) based on patient-reported severity and impact of UI (ICIQ-UI SF). Health care resource use, patient and family costs, and productivity costs were assessed. Data were collected by three monthly questionnaires. Incremental cost-effectiveness ratios were calculated. Uncertainty was assessed using bootstrap simulation, and the expected value of perfect information was calculated (EVPI). RESULTS: Compared to care-as-usual, nurse specialist involvement costs € 16,742/QALY(societal) gained. Both QALY(patient) and ISLY yield slightly more favorable cost-effectiveness results. At a threshold of € 40,000/QALY(societal,) the probability that the intervention is cost-effective is 58%. The EVPI amounts to € 78 million. CONCLUSIONS: Based on these results, we recommend adopting the nurse specialist intervention in primary care, while conducting more research through careful monitoring of the effectiveness and costs of the intervention in routine practice.

Health indicators in the European regions: expanding regional comparisons to the new countries of the European Union - ISARE III.

OBJECTIVES: Most comparisons of health in Europe take place at the national level. However, there is increased interest in looking at health data at a sub-national level. This study aimed to establish the availability of health data at a regional level and to develop a methodology for the comparisons of health indicators at a sub-national level. In previous work on indicators at a regional level in the European Union, the authors recommended the development of such indicators. This paper takes into account the expansion of the European Union which took place in 2004. STUDY DESIGN: Observational study using routinely available data. METHODS: Similar to previous projects, a network of country correspondents was used and data were collected on a similar range of topics. In addition, a supplementary list of data was collected from one region of each country. RESULTS: Twenty-three countries out of the 25 member states of the European Union participated in the study. Where available, data were of relatively good quality. Data on mortality were most readily available, but data on important public health topics such as obesity were much more difficult to obtain. CONCLUSIONS: A database and a set of indicators for relevant sub-national areas of countries in the European Union, including new countries, were constructed. Data collection from the new countries was more straightforward due to the requirement for them to adhere to the nomenclature of territorial units for statistics (NUTS) levels. The lack of adherence to NUTS levels in the 'old' countries of the European Union continues to create problems. There remains an urgent need to introduce comprehensive sub-national data collection on important public health topics such as obesity and smoking.

Effects of Macroplastique Implantation System for stress urinary incontinence and urethral hypermobility in women.

A study was carried out to evaluate efficacy of Macroplastique(R) (MPQ) Implantation System (MIS) in women with urodynamic stress urinary incontinence (SUI) and urethral hypermobility after an unsuccessful conservative treatment. This is a prospective randomized controlled trial in women without previous incontinence surgery. Twenty-four women received MPQ. Twenty-one controls underwent a pelvic floor muscle exercises home program. Follow-up was at 3 months and the MPQ group also at 12 months. At 3 months, pad usage decreased significantly more in the MPQ group than in the control group (p = 0.015). According to physician and patient self-assessment, respectively, 71% and 63% women in the MPQ group were considered cured or markedly improved. This was significantly higher compared to controls. There was a significant higher increase of Incontinence Quality-of-Life questionnaire score in the MPQ group compared to controls (p = 0.017). Improvements in MPQ group at 3 months are sustained to 12 months. Adverse events were mild and transient. MIS is an acceptable option for women with SUI and urethral hypermobility.

WITHDRAWN: Pelvic floor muscle training for urinary incontinence in women.

BACKGROUND: Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress leakage of urine. It is also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. Adjuncts, such as biofeedback or electrical stimulation, are also commonly used with pelvic floor muscle training. The content of pelvic floor muscle training programmes is highly variable. OBJECTIVES: To determine the effects of pelvic floor muscle training for women with symptoms or urodynamic diagnoses of stress, urge and mixed incontinence, in comparison to no treatment or other treatment options. SEARCH STRATEGY: Search strategy: We searched the Cochrane Incontinence Group trials register (May 2000), Medline (1980 to 1998), Embase (1980 to 1998), the database of the Dutch National Institute of Allied Health Professions (to 1998), the database of the Cochrane Rehabilitation and Related Therapies Field (to 1998), Physiotherapy Index (to 1998) and the reference lists of relevant articles. We handsearched the proceedings of the International Continence Society (1980 to 2000). We contacted investigators in the field to locate studies. Date of the most recent searches: May 2000. SELECTION CRITERIA: Randomised trials in women with symptoms or urodynamic diagnoses of stress, urge or mixed incontinence that included pelvic floor muscle training in at least one arm of the trial. DATA COLLECTION AND ANALYSIS: Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Sensitivity analysis on the basis of diagnosis was planned and undertaken where appropriate. MAIN RESULTS: Forty-three trials met the inclusion criteria. The primary or only reference for 15 of these was a conference abstract. The pelvic floor muscle training programs, and comparison interventions, varied markedly. Outcome measures differed between trials, and methods of data reporting varied, making the data difficult to combine. Many of the trials were small. Allocation concealment was adequate in five trials, and nine trials used assessors masked to group allocation. Thirteen trials reported that there were no losses to follow up, seven trials had dropout rates of less than 10%, but in the remaining trials the proportion of dropouts ranged from 12% to 41%. Pelvic floor muscle training was better than no treatment or placebo treatments for women with stress or mixed incontinence. 'Intensive' appeared to be better than 'standard' pelvic floor muscle training. PFMT may be more effective than some types of electrical stimulation but there were problems in combining the data from these trials. There is insufficient evidence to determine if pelvic floor muscle training is better or worse than other treatments. The effect of adding pelvic floor muscle training to other treatments (e.g. electrical stimulation, behavioural training) is not clear due to the limited amount of evidence available. Evidence of the effect of adding other adjunctive treatments to PFMT (e.g. vaginal cones, intravaginal resistance) is equally limited. The effectiveness of biofeedback assisted PFMT is not clear, but on the basis of the evidence available there did not appear to be any benefit over PFMT alone at post treatment assessment.Long-term outcomes of pelvic floor muscle training are unclear. Side effects of pelvic floor muscle training were uncommon and reversible. A number of the formal comparisons should be viewed with caution due to statistical heterogeneity, lack of statistical independence, and the possibility of spurious confidence intervals in some instances. AUTHORS' CONCLUSIONS: Pelvic floor muscle training appeared to be an effective treatment for adult women with stress or mixed incontinence. Pelvic floor muscle training was better than no treatment or placebo treatments. The limitations of the evidence available mean that is difficult to judge if pelvic floor muscle training was better or worse than other treatments. Most trials to date have studied the effect of treatment in younger, premenopausal women. The role of pelvic floor muscle training for women with urge incontinence alone remains unclear. Many of the trials were small with poor reporting of allocation concealment and masking of outcome assessors. In addition there was a lack of consistency in the choice and reporting of outcome measures that made data difficult to combine. Methodological problems limit the confidence that can be placed in the findings of the review. Further, large, high quality trials are necessary.

Is obesity associated with injuries among young people?

OBJECTIVES: To look at the relationship between obesity and trauma among young people in the Hainaut Province in Belgium. DESIGN: A cross-sectional study (questionnaire and physical examination) was conduced among a sample of 2363 children of 9- to 17-year-olds (n = 2363) in 1998. RESULTS: In the past 12 months prior to the survey, 37% of the sample had at least one injury requiring treatment (with or without hospitalization), and 5% had a severe injury (with at least one night at the hospital). More than 15% were classified to be obese according to the WHO definition. We observed a significantly higher frequency of injury in obese people, in boys, in subjects playing sport intensively, with members of a sports club and in those reporting more than one physical activity per week. In multivariate analysis for injury, gender, physical activity, playing sport in a club and obesity were significant. For severe injuries, only gender and physical activity remained significant in the multivariate analysis. CONCLUSION: Our analysis shows that childhood obesity and physical activity increase the occurrence of injuries. However, we did not observe an association between obesity and severe injuries. Obesity as a risk factor for the occurrence of injuries has to be confirmed by other studies, and the understanding of the mechanism for the observed association needs more investigation.

Systematic review: efficacy of silicone microimplants (Macroplastique) therapy for stress urinary incontinence in adult women.

OBJECTIVE: To assess the efficacy of silicone microimplants (Macroplastique; polydimethylsiloxane) therapy for stress urinary incontinence in adult women, using a systematic review of identified studies. MATERIALS AND METHODS: A computer-aided and manual search for published studies investigating silicone microimplants therapy for stress urinary incontinence in adult women. The methodological quality of the included studies was assessed using criteria based on generally accepted principles of interventional research. RESULTS: Only two RCTs, only published as an abstract, were found. Eleven pre-experimental or observational studies were identified. Overall, the methodological quality was low. The main methodological shortcomings of the studies were: no random allocation procedure, lack of prestratification on prognostic determinants, no blinding, small sample sizes, and lack of proper analysis and presentation of results. There was variability in the indication for implantation, implantation procedure, rate and volume of silicone microimplants. The use of different outcome measures in most of the trials made comparison between studies difficult. CONCLUSIONS: Because of the low methodological quality of included studies, results should be interpreted with caution and no firm conclusions about the efficacy of silicone microimplants were possible. Randomized clinical trials, using valid and reliable subjective and objective measurements, are necessary to establish the efficacy of silicone microimplants therapy in treating stress urinary incontinence in adult women.

Pelvic floor muscle training for urinary incontinence in women.

BACKGROUND: Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress leakage of urine. It is also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. Adjuncts, such as biofeedback or electrical stimulation, are also commonly used with pelvic floor muscle training. The content of pelvic floor muscle training programmes is highly variable. OBJECTIVES: To determine the effects of pelvic floor muscle training for women with symptoms or urodynamic diagnoses of stress, urge and mixed incontinence, in comparison to no treatment or other treatment options. SEARCH STRATEGY: Search strategy: We searched the Cochrane Incontinence Group trials register (May 2000), Medline (1980 to 1998), Embase (1980 to 1998), the database of the Dutch National Institute of Allied Health Professions (to 1998), the database of the Cochrane Rehabilitation and Related Therapies Field (to 1998), Physiotherapy Index (to 1998) and the reference lists of relevant articles. We handsearched the proceedings of the International Continence Society (1980 to 2000). We contacted investigators in the field to locate studies. Date of the most recent searches: May 2000. SELECTION CRITERIA: Randomised trials in women with symptoms or urodynamic diagnoses of stress, urge or mixed incontinence that included pelvic floor muscle training in at least one arm of the trial. DATA COLLECTION AND ANALYSIS: Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Sensitivity analysis on the basis of diagnosis was planned and undertaken where appropriate. MAIN RESULTS: Forty-three trials met the inclusion criteria. The primary or only reference for 15 of these was a conference abstract. The pelvic floor muscle training programs, and comparison interventions, varied markedly. Outcome measures differed between trials, and methods of data reporting varied, making the data difficult to combine. Many of the trials were small. Allocation concealment was adequate in five trials, and nine trials used assessors masked to group allocation. Thirteen trials reported that there were no losses to follow up, seven trials had dropout rates of less than 10%, but in the remaining trials the proportion of dropouts ranged from 12% to 41%. Pelvic floor muscle training was better than no treatment or placebo treatments for women with stress or mixed incontinence. 'Intensive' appeared to be better than 'standard' pelvic floor muscle training. PFMT may be more effective than some types of electrical stimulation but there were problems in combining the data from these trials. There is insufficient evidence to determine if pelvic floor muscle training is better or worse than other treatments. The effect of adding pelvic floor muscle training to other treatments (e.g. electrical stimulation, behavioural training) is not clear due to the limited amount of evidence available. Evidence of the effect of adding other adjunctive treatments to PFMT (e.g. vaginal cones, intravaginal resistance) is equally limited. The effectiveness of biofeedback assisted PFMT is not clear, but on the basis of the evidence available there did not appear to be any benefit over PFMT alone at post treatment assessment. Long-term outcomes of pelvic floor muscle training are unclear. Side effects of pelvic floor muscle training were uncommon and reversible. A number of the formal comparisons should be viewed with caution due to statistical heterogeneity, lack of statistical independence, and the possibility of spurious confidence intervals in some instances. REVIEWER'S CONCLUSIONS: Pelvic floor muscle training appeared to be an effective treatment for adult women with stress or mixed incontinence. Pelvic floor muscle training was better than no treatment or placebo treatments. The limitations of the evidence available mean that is difficult to judge if pelvic floor muscle training was better or worse than other treatments. Most trials to date have studied the effect of treatment in younger, premenopausal women. The role of pelvic floor muscle training for women with urge incontinence alone remains unclear. Many of the trials were small with poor reporting of allocation concealment and masking of outcome assessors. In addition there was a lack of consistency in the choice and reporting of outcome measures that made data difficult to combine. Methodological problems limit the confidence that can be placed in the findings of the review. Further, large, high quality trials are necessary.

Blood pressure measurement in epidemiological investigations in teenagers.

BACKGROUND: The use of sphygmomanometers may lead to problems in investigations on health of young people. The purpose of this paper is to present the validation of the blood pressure (BP) collected during the survey 'Youth Heart Health' in Hainaut by using second sample of young people in Hainaut for which BP was measured by a manual taking of tension and by an electronic device. METHODS: Validation was done with a control sample of 343 young with five successive BP measures: twice with the mercury sphygmomanometer and three with DXL. We compared the manual and the electronic measures in order to study the correlation between the two methods. The control sample was used in order to compare the BP measurements with the results of the survey on the health of young people in Hainaut. RESULTS: The differences between manual systolic BP and Dinamap measures are significant (differences in averages 3.6 mmHg; d.s. 7.8; 95% CI: 2.8-4.4 mmHg; p < 0.001) and the regression coefficient is -0.015. Diastolic BP is significantly higher with the manual method than with Dinamap (differences in means: 8.2 mmHg; d.s. 7.0; 95% CI: 7.4-8.9 mmHg; p < 0.001) and the coefficient of regression is 0.096. We observe a difference in BP between the general survey and the control group (10.3 mmHg for systolic manual control and of 10.9 mmHg for systolic electronic control; 3.3 mmHg for diastolic manual control and of 11.5 mmHg for diastolic electronic control). CONCLUSIONS: The values of BP of the 'Youth Heart Health' are significantly higher. These observations indicate the difficulties in the choice of the tool for measurements of BP in epidemiological investigations in the teenagers. In order to decrease skews of observations in the measurement of BP, it is recommended to use a valid electronic instrument. Dinamap XL is an instrument of choice in such studies of young people. Environmental and organisational factors may also explain the observed difference, which means that survey's protocols should address this issue carefully.

Nonpharmacologic treatments for overactive bladder-pelvic floor exercises.

The theory behind the use of physical therapies (electrical stimulation or pelvic floor muscle [PFM] training with or without biofeedback) for overactive bladder is to (1) inhibit detrusor muscle contraction by voluntary contraction of the PFMs at the same time as the urge to void; and (2) prevent sudden falls in urethral pressure by a change in PFM morphology, position, and neuromuscular function. Few trials have evaluated the effect of PFM training on symptoms of overactive bladder. Most studies are flawed because they include several diagnoses and treatment modalities in the same intervention. Because of the lack of evidence, no firm conclusion can be drawn on the effect of PFM exercise on overactive bladder. There are some initially promising results, but there is still a need for high-quality, randomized controlled trials on the effect of PFM training on the inhibition of detrusor contraction in human beings. The efficacy of PFM training in combination with other treatments, such as pharmacotherapy, also requires investigation.

Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials.

OBJECTIVE: To assess the efficacy of physical therapies for first-line use in the treatment of urge urinary incontinence (UUI) in women, using a systematic review of randomized clinical trials (RCTs). MATERIALS AND METHODS: A computer-aided and manual search was carried out for RCTs published between 1980 and 1999 investigating the treatment of UUI defined by the keywords 'physical therapies', e.g. bladder (re)training (including 'behavioural' treatment), pelvic floor muscle (PFM) exercises, with or without biofeedback and/or electrical stimulation. The methodological quality of the included trials was assessed using methodological criteria, based on generally accepted principles of interventional research. RESULTS: Fifteen RCTs were identified; the methodological quality of the studies was moderate, with a median (range) score of 6 (3-8.5) (maximum possible 10). Eight RCTs were considered of sufficient quality, i.e. an internal validity score of >/= 5.5 points on a scale of 0-10, and were included in a further analysis. Based on levels-of-evidence criteria, there is weak evidence to suggest that bladder (re)training is more effective than no treatment (controls), and that bladder (re)training is better than drug therapy. Stimulation types and parameters in the studies of electrical stimulation were heterogeneous. There is insufficient evidence that electrical stimulation is more effective than sham electrical simulation. To date there are too few studies to evaluate effects of PFM exercise with or without biofeedback, and of toilet training for women with UUI. CONCLUSION: Although almost all studies included reported positive results in favour of physical therapies for the treatment of UUI, more research of high methodological quality is required to evaluate the effects of each method in the range of physical therapies.

Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials.

OBJECTIVE: To assess the efficacy of physical therapies for first-line use in the treatment and prevention of stress urinary incontinence (SUI) in women, using a systematic review of randomized clinical trials (RCTs). MATERIALS AND METHODS: A computer-aided and manual search for published RCTs investigating treatment and prevention of SUI using physical therapies, e.g. pelvic floor muscle (PFM) exercises, with or without other treatment modalities, were carried out. The methodological quality of the included trials was assessed using criteria based on generally accepted principles of interventional research. RESULTS: Twenty-four RCTs (22 treatment and two prevention) were identified; the methodological quality of the studies included was moderate and 11 RCTs were of sufficient quality to be included in further analysis. Based on levels-of-evidence criteria, there is strong evidence to suggest that PFM exercises are effective in reducing the symptoms of SUI. There is limited evidence for the efficacy of high-intensity vs a low-intensity regimen of PFM exercises. Despite significant effects of biofeedback after testing as an adjunct to PFM exercises, there is no evidence that PFM exercises with biofeedback are more effective than PFM exercises alone. There is little consistency (of stimulation types and parameters) in the studies of electrical stimulation, but when the results are combined there is strong evidence to suggest that electrostimulation is superior to sham electrostimulation, and limited evidence that there is no difference between electrostimulation and other physical therapies. In the prevention of SUI the efficacy of PFM exercises, with or without other adjuncts, is uncertain.

Efficacy of biofeedback, when included with pelvic floor muscle exercise treatment, for genuine stress incontinence.

UNLABELLED: We performed a randomized clinical trial on the efficacy of physical therapy on genuine stress incontinence. STUDY OBJECTIVE: "Is a physical therapeutical training program (pelvic floor muscle training) combined with biofeedback, more effective than the same program without biofeedback in patients with mild or moderate stress incontinence?" Forty-four patients were referred by a general practitioner or a urologist. After informed consent, 40 patients were randomized in an exercises and biofeedback group (BF), or treated with exercises exclusively (pelvic floor muscle training = PFMT). After a diagnostic phase of 1 week every patient received twelve treatment sessions, three times weekly. The primary measure of effect, the quantity of involuntary urine loss, was measured with the 48 hours PAD test (Inco-test Mölnlycke). Before every treatment session the Symptoms questionnaire was filed out by the patient and the Patient dairy was controlled. The data of the trial were analysed according to the principal of intention to treat. During the trial there was 100% compliance. There were no drop-outs. Both treatment modalities appeared to be effective. After twelve treatment sessions there was a mean improvement of +/- 55% (P = 0.00) in both treatment groups, measured by the primary measure of effect. In the group with BF this improvement was already realized after six treatment sessions (P = 0.01). Yet, the difference between BF and PFMT faded to reach significance at six treatment sessions (P = 0.08). Although differences in treatment effects between both groups were not significant, our findings suggest that adding biofeedback to pelvic floor muscle exercises might be more effective than pelvic floor muscle exercises alone after six treatments.

[Hyperlipidemia and atherosclerosis: epidemiology, biochemistry and therapy]. / Hyperlipidémie et athérosclérose: épidémiologie, biochimie et thérapeutique.

Cardiovascular diseases cause 40% of deaths in Belgium. The coronary risk is more important in the Southern than in the Northern part of the country, owing probably to different levels of serum cholesterol due to different fat contents of the diet. The features of lipoprotein metabolism are mainly the permanent transfer of apoproteins and the dynamic exchange of neutral lipids. Atherogenic particles include remnants enriched in cholesterol esters and low density lipoproteins (LDL) after their oxidation. New European guidelines insist more on secondary prevention than on primary prevention.

National study on the utilization of prophylactic antibiotics in surgery, Belgium, 1986.

During the last week of May 1986, a 1-week prospective study on antibiotic utilization in surgical patients was held in 104 (42%) of the 247 Belgian acute care hospitals. All surgical patients with a post-operative stay of at least 3 days were studied, involving 3112 patients. Each patient was observed for 7 days, starting from the day before surgery. Antibiotics were administered to 71.9% of all patients; 21.9% received therapeutic antibiotics and 52.9% prophylactic antibiotics; 2.9% received both. Of the 1285 patients undergoing a surgical procedure with no indication for antimicrobial prophylaxis, 50.7% nevertheless received prophylaxis; 92.8% of patients with a generally recognized indication for prophylaxis received antibiotic prophylaxis. Less than one fifth (17.1%) of all prophylactic courses were stopped on the day of the intervention whilst 26.3% were continued up to the fifth post-operative day or beyond. The most frequently prescribed drugs for this indication included first and second generation cephalosporins and nitroimidazoles. The number of different generic drugs utilized per hospital ranged from 1 to 18 (mean: 7.7).

Behavior of a respiratory driven pacemaker and direct respiratory measurements.

In 10 patients with a mean age of 76 +/- 8 years, a rate responsive pacemaker (Meta-MV, Telectronics) was implanted in the left pectoral site. An exercise test was performed in SSI ("adaptive") mode, allowing the device to measure the changes in thoracic impedance. The "slope number" at maximal exercise was chosen to program the pacemaker for a second exercise test in rate responsive mode. Direct measurements of respiratory rate and minute volume were correlated with the pacing rate. After 1 minute of exercise, pacing rate increased by 6% and it decreased smoothly after maximal exercise. The programmed maximal rate was reached at the maximum exercise level in six patients. During 24-hour Holter recording, the mean maximal pacing rate was 103 +/- 18 beats/min. For individual patients, a good correlation of pacing rate with respiratory rate (r = 0.757), oxygen consumption (r = 0.731), and minute volume (r = 0.800) was observed. The data from the entire group showed a highly significant correlation of changes in pacing rate and in respiratory parameters for different levels of exercise and recovery. In a subgroup of five patients, the slope numbers at maximal exercise were reproducible after 10 months. It was concluded that minute volume and its changes were recognized in a reliable way by the Meta-MV pacemaker.