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Background: Pelvic floor muscle training (PFMT) is a first-line conservative treatment for urinary incontinence in women. Other active treatments include: physical therapies (e.g. vaginal cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation; mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics (solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including sling procedures and colposuspension. This systematic review evaluated the effects of adding PFMT to any other active treatment for urinary incontinence in women, Objectives: To compare the effects of pelvic floor muscle training combined with another active treatment versus the same active treatment alone in the management of women with urinary incontinence., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 5 May 2015), and CINAHL (January 1982 to 6 May 2015), and the reference lists of relevant articles., Selection Criteria: We included randomised or quasi-randomised trials with two or more arms, of women with clinical or urodynamic evidence of stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. One arm of the trial included PFMT added to another active treatment; the other arm included the same active treatment alone., Data Collection and Analysis: Two review authors independently assessed trials for eligibility and methodological quality and resolved any disagreement by discussion or consultation with a third party. We extracted and processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other potential sources of bias we incorporated into the 'Risk of bias' tables were ethical approval, conflict of interest and funding source., Main Results: Thirteen trials met the inclusion criteria, comprising women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI); they compared PFMT added to another active treatment (585 women) with the same active treatment alone (579 women). The pre-specified comparisons were reported by single trials, except bladder training, which was reported by two trials, and electrical stimulation, which was reported by three trials. However, only two of the three trials reporting electrical stimulation could be pooled, as one of the trials did not report any relevant data. We considered the included trials to be at unclear risk of bias for most of the domains, predominantly due to the lack of adequate information in a number of trials. This affected our rating of the quality of evidence. The majority of the trials did not report the primary outcomes specified in the review (cure or improvement, quality of life) or measured the outcomes in different ways. Effect estimates from small, single trials across a number of comparisons were indeterminate for key outcomes relating to symptoms, and we rated the quality of evidence, using the GRADE approach, as either low or very low. More women reported cure or improvement of incontinence in two trials comparing PFMT added to electrical stimulation to electrical stimulation alone, in women with SUI, but this was not statistically significant (9/26 (35%) versus 5/30 (17%); risk ratio (RR) 2.06, 95% confidence interval (CI) 0.79 to 5.38). We judged the quality of the evidence to be very low. There was moderate-quality evidence from a single trial investigating women with SUI, UUI or MUI that a higher proportion of women who received a combination of PFMT and heat and steam generating sheet reported a cure compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with a RR of 2.38, 95% CI 1.19 to 4.73). More women reported cure or improvement of incontinence in another trial comparing PFMT added to vaginal cones to vaginal cones alone, but this was not statistically significant (14/15 (93%) versus 14/19 (75%); RR 1.27, 95% CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial evaluating PFMT when added to drug therapy provided information about adverse events (RR 0.84, 95% CI 0.45 to 1.60; very low-quality evidence).With regard to condition-specific quality of life, there were no statistically significant differences between women (with SUI, UUI or MUI) who received PFMT added to bladder training and those who received bladder training alone at three months after treatment, on either the Incontinence Impact Questionnaire-Revised scale (mean difference (MD) -5.90, 95% CI -35.53 to 23.73) or on the Urogenital Distress Inventory scale (MD -18.90, 95% CI -37.92 to 0.12). A similar pattern of results was observed between women with SUI who received PFMT plus either a continence pessary or duloxetine and those who received the continence pessary or duloxetine alone. In all these comparisons, the quality of the evidence for the reported critical outcomes ranged from moderate to very low., Authors' Conclusions: This systematic review found insufficient evidence to state whether or not there were additional effects by adding PFMT to other active treatments when compared with the same active treatment alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be interpreted with caution as most of the comparisons were investigated in small, single trials. None of the trials in this review were large enough to provide reliable evidence. Also, none of the included trials reported data on adverse events associated with the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.

Background: Goal setting is considered a key component of rehabilitation for adults with acquired disability, yet there is little consensus regarding the best strategies for undertaking goal setting and in which clinical contexts. It has also been unclear what effect, if any, goal setting has on health outcomes after rehabilitation., Objectives: To assess the effects of goal setting and strategies to enhance the pursuit of goals (i.e. how goals and progress towards goals are communicated, used, or shared) on improving health outcomes in adults with acquired disability participating in rehabilitation., Search Methods: We searched CENTRAL, MEDLINE, EMBASE, four other databases and three trials registers to December 2013, together with reference checking, citation searching and contact with study authors to identify additional studies. We did not impose any language or date restrictions., Selection Criteria: Randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs evaluating the effects of goal setting or strategies to enhance goal pursuit in the context of adult rehabilitation for acquired disability., Data Collection and Analysis: Two authors independently reviewed search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information., Main Results: We included 39 studies (27 RCTs, 6 cluster-RCTs, and 6 quasi-RCTs) involving 2846 participants in total. Studies ranged widely regarding clinical context and participants' primary health conditions. The most common health conditions included musculoskeletal disorders, brain injury, chronic pain, mental health conditions, and cardiovascular disease.Eighteen studies compared goal setting, with or without strategies to enhance goal pursuit, to no goal setting. These studies provide very low quality evidence that including any type of goal setting in the practice of adult rehabilitation is better than no goal setting for health-related quality of life or self-reported emotional status (8 studies; 446 participants; standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.17 to 0.88, indicative of a moderate effect size) and self-efficacy (3 studies; 108 participants; SMD 1.07, 95% CI 0.64 to 1.49, indicative of a moderate to large effect size). The evidence is inconclusive regarding whether goal setting results in improvements in social participation or activity levels, body structure or function, or levels of patient engagement in the rehabilitation process. Insufficient data are available to determine whether or not goal setting is associated with more or fewer adverse events compared to no goal setting.Fourteen studies compared structured goal setting approaches, with or without strategies to enhance goal pursuit, to 'usual care' that may have involved some goal setting but where no structured approach was followed. These studies provide very low quality evidence that more structured goal setting results in higher patient self-efficacy (2 studies; 134 participants; SMD 0.37, 95% CI 0.02 to 0.71, indicative of a small effect size) and low quality evidence for greater satisfaction with service delivery (5 studies; 309 participants; SMD 0.33, 95% CI 0.10 to 0.56, indicative of a small effect size). The evidence was inconclusive regarding whether more structured goal setting approaches result in higher health-related quality of life or self-reported emotional status, social participation, activity levels, or improvements in body structure or function. Three studies in this group reported on adverse events (death, re-hospitalisation, or worsening symptoms), but insufficient data are available to determine whether structured goal setting is associated with more or fewer adverse events than usual care.A moderate degree of heterogeneity was observed in outcomes across all studies, but an insufficient number of studies was available to permit subgroup analysis to explore the reasons for this heterogeneity. The review also considers studies which investigate the effects of different approaches to enhancing goal pursuit, and studies which investigate different structured goal setting approaches. It also reports on secondary outcomes including goal attainment and healthcare utilisation., Authors' Conclusions: There is some very low quality evidence that goal setting may improve some outcomes for adults receiving rehabilitation for acquired disability. The best of this evidence appears to favour positive effects for psychosocial outcomes (i.e. health-related quality of life, emotional status, and self-efficacy) rather than physical ones. Due to study limitations, there is considerable uncertainty regarding these effects however, and further research is highly likely to change reported estimates of effect.

Community scholars increasingly focus on the linkage between residents' sense of cohesion with the neighborhood and their own social networks in the neighborhood. A challenge is that whereas some research only focuses on residents' social ties with fellow neighbors, such an approach misses out on the larger constellation of individuals' relationships and the spatial distribution of those relationships. Using data from the Twin Communities Network Study, the current project is one of the first studies to examine the actual spatial distribution of respondents' networks for a variety of relationships and the consequences of these for neighborhood and city cohesion. We also examine how a perceived structural measure of cohesion-triangle degree-impacts their perceptions of neighborhood and city cohesion. Our findings suggest that perceptions of cohesion within the neighborhood and the city depend on the number of neighborhood safety contacts as well as on the types of people with which they discuss important matters. On the other hand, kin and social friendship ties do not impact cohesion. A key finding is that residents who report more spatially dispersed networks for certain types of ties report lower levels of neighborhood and city cohesion. Residents with higher triangle degree within their neighborhood safety networks perceived more neighborhood cohesion.

Background: Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed and, less commonly, urgency urinary incontinence., Objectives: To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (1999 onwards), MEDLINE (1966 onwards) and MEDLINE In-Process (2001 onwards), and handsearched journals and conference proceedings (searched 15 April 2013) and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs, or urodynamics). One arm of the trial included pelvic floor muscle training (PFMT). Another arm was a no treatment, placebo, sham, or other inactive control treatment arm., Data Collection and Analysis: Trials were independently assessed by two review authors for eligibility and methodological quality. Data were extracted then cross-checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Trials were subgrouped by diagnosis of urinary incontinence. Formal meta-analysis was undertaken when appropriate., Main Results: Twenty-one trials involving 1281 women (665 PFMT, 616 controls) met the inclusion criteria; 18 trials (1051 women) contributed data to the forest plots. The trials were generally small to moderate sized, and many were at moderate risk of bias, based on the trial reports. There was considerable variation in the interventions used, study populations, and outcome measures. There were no studies of women with mixed or urgency urinary incontinence alone.Women with SUI who were in the PFMT groups were 8 times more likely than the controls to report that they were cured (46/82 (56.1%) versus 5/83 (6.0%), RR 8.38, 95% CI 3.68 to 19.07) and 17 times more likely to report cure or improvement (32/58 (55%) versus 2/63 (3.2%), RR 17.33, 95% CI 4.31 to 69.64). In trials in women with any type of urinary incontinence, PFMT groups were also more likely to report cure, or more cure and improvement than the women in the control groups, although the effect size was reduced. Women with either SUI or any type of urinary incontinence were also more satisfied with the active treatment, while women in the control groups were more likely to seek further treatment. Women treated with PFMT leaked urine less often, lost smaller amounts on the short office-based pad test, and emptied their bladders less often during the day. Their sexual outcomes were also better. Two trials (one small and one moderate size) reported some evidence of the benefit persisting for up to a year after treatment. Of the few adverse effects reported, none were serious.The findings of the review were largely supported by the summary of findings tables, but most of the evidence was down-graded to moderate on methodological grounds. The exception was 'Participant perceived cure' in women with SUI, which was rated as high quality., Authors' Conclusions: The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence. Long-term effectiveness of PFMT needs to be further researched.

Background: Pelvic floor muscle training (PFMT) is a first-line conservative treatment for urinary incontinence in women. Other active treatments include: physical therapies (e.g. vaginal cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation; mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics (solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including sling procedures and colposuspension. This systematic review evaluated the effects of adding PFMT to any other active treatment for urinary incontinence in women, Objectives: To compare the effects of pelvic floor muscle training combined with another active treatment versus the same active treatment alone in the management of women with urinary incontinence., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 28 February 2013), EMBASE (January 1947 to 2013 Week 9), CINAHL (January 1982 to 5 March 2013), ClinicalTrials.gov (searched 30 May 2013), WHO ICTRP (searched 3 June 2013) and the reference lists of relevant articles., Selection Criteria: We included randomised or quasi-randomised trials with two or more arms in women with clinical or urodynamic evidence of stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. One arm of the trial included PFMT added to another active treatment; the other arm included the same active treatment alone., Data Collection and Analysis: Two review authors independently assessed trials for eligibility and methodological quality and resolved any disagreement by discussion or consultation with a third party. We extracted and processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other potential sources of bias we incorporated into the 'Risk of bias' tables were ethical approval, conflict of interest and funding source., Main Results: Eleven trials met the eligibility criteria for inclusion, comprising women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI), and they compared PFMT added to another active treatment (494 women) with the same active treatment alone (490 women). The pre-specified comparisons were reported by single trials except electrical stimulation which was reported by two trials. However, the two trials reporting electrical stimulation could not be pooled as one of the trials did not report any relevant data. We considered the included trials to be at unclear risk of bias for most of the domains, predominantly due to the lack of adequate information in a number of trials. This affected our rating of the quality of evidence. The majority of the trials did not report the primary outcomes specified in the review (cure/improvement, quality of life) or measured the outcomes in different ways. Effect estimates from small, single trials across a number of comparisons were indeterminate for key outcomes relating to symptoms and we rated the quality of evidence, using the GRADE approach, as either low or very low. There was moderate-quality evidence from a single trial investigating women with SUI, UUI or MUI that a higher proportion of women who received a combination of PFMT and heat and steam generating sheet reported cure compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with a risk ratio (RR) of 2.38, 95% confidence interval (CI) 1.19 to 4.73). More women reported cure or improvement of incontinence in another trial comparing PFMT added to vaginal cones to vaginal cones alone: 14/15 (93%) versus 14/19 (75%), but this was not statistically significant (RR 1.27, 95% CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial evaluating PFMT when added to drug therapy provided information about adverse events (RR 0.84, 95% CI 0.45 to 1.60; very low-quality evidence).With regard to condition-specific quality of life, there were no statistically significant differences between women (with SUI, UUI or MUI) who received PFMT added to bladder training and those who received bladder training alone at three months after treatment either on the Incontinence Impact Questionnaire-Revised scale (mean difference (MD) -5.90, 95% CI -35.53 to 23.73) or on the Urogenital Distress Inventory scale (MD -18.90, 95% CI -37.92 to 0.12). A similar pattern of results was observed between women with SUI who received PFMT plus either a continence pessary or duloxetine and those who received the continence pessary or duloxetine alone. In all these comparisons, the quality of the evidence for the reported critical outcomes ranged from moderate to very low., Authors' Conclusions: This systematic review found insufficient evidence to state whether or not there were additional effects of adding PFMT to other active treatment when compared with the same active treatment alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be interpreted with caution as most of the comparisons were investigated in small, single trials. None of the trials in this review were large enough to provide reliable evidence. Also, none of the included trials reported data on adverse events associated with the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.

Background: About a third of women have urinary incontinence and up to a 10th have faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and the treatment of incontinence., Objectives: To determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which includes searches of CENTRAL, MEDLINE, MEDLINE in Process and handsearching (searched 7 February 2012) and the references of relevant articles., Selection Criteria: Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial needed to include pelvic floor muscle training (PFMT). Another arm was either no PFMT or usual antenatal or postnatal care., Data Collection and Analysis: Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Three different populations of women were considered separately, women dry at randomisation (prevention); women wet at randomisation (treatment); and a mixed population of women who might be one or the other (prevention or treatment). Trials were further divided into those which started during pregnancy (antenatal); and those started after delivery (postnatal)., Main Results: Twenty-two trials involving 8485 women (4231 PFMT, 4254 controls) met the inclusion criteria and contributed to the analysis.Pregnant women without prior urinary incontinence (prevention) who were randomised to intensive antenatal PFMT were less likely than women randomised to no PFMT or usual antenatal care to report urinary incontinence up to six months after delivery (about 30% less; risk ratio (RR) 0.71, 95% CI 0.54 to 0.95, combined result of 5 trials).Postnatal women with persistent urinary incontinence (treatment) three months after delivery and who received PFMT were less likely than women who did not receive treatment or received usual postnatal care to report urinary incontinence 12 months after delivery (about 40% less; RR 0.60, 95% CI 0.35 to 1.03, combined result of 3 trials). It seemed that the more intensive the programme the greater the treatment effect.The results of seven studies showed a statistically significant result favouring PFMT in a mixed population (women with and without incontinence symptoms) in late pregnancy (RR 0.74, 95% CI 0.58 to 0.94, random-effects model). Based on the trial data to date, the extent to which mixed prevention and treatment approaches to PFMT in the postnatal period are effective is less clear (that is, offering advice on PFMT to all pregnant or postpartum women whether they have incontinence symptoms or not). It is possible that mixed prevention and treatment approaches might be effective when the intervention is intensive enough.There was little evidence about long-term effects for either urinary or faecal incontinence., Authors' Conclusions: There is some evidence that for women having their first baby, PFMT can prevent urinary incontinence up to six months after delivery. There is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery). These and other uncertainties, particularly long-term effectiveness, require further testing.

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 Methods: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 March 2011) and reference lists of relevant articles., 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: Eighty six trials, 70 parallel and 16 cross-over designs were included (31,249 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-analyses. Twenty nine collected quality of life data (the primary outcome measure) using validated measures, but only fifteen reported useable data.Tolterodine versus oxybutynin: There were no statistically significant differences for quality of life, patient reported cure or improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events with tolterodine (Risk Ratio (RR) 0.52, 95% confidence interval (CI) 0.40 to 0.66, data from eight trials), and less risk of dry mouth (RR 0.65, 95% CI 0.60 to 0.71, data from ten trials).Solifenacin versus tolterodine: There were statistically significant differences for quality of life (standardised mean difference (SMD) -0.12, 95% CI -0.23 to -0.01, data from three trials), patient reported cure/improvement (RR 1.25, 95% CI 1.13 to 1.39, data from two trials), leakage episodes in 24 hours (weighted mean difference (WMD) -0.30, 95% CI -0.53 to -0.08, data from four studies) and urgency episodes in 24 hours (WMD -0.43, 95% CI -0.74 to -0.13, data from four trials), all favouring solifenacin. There was no difference in withdrawals due to adverse events and dry mouth, but after sensitivity analysis the dry mouth (RR 0.69, 95% CI 0.51 to 0.94) was statistically significantly lower with solifenacin when compared to Immediate Release (IR) tolterodine.Fesoterodine versus extended release tolterodine: Three trials contributed to the meta analyses. There were statistically significant differences for quality of life (SMD -0.20, 95% CI -0.27 to -0.14), patient reported cure/improvement (RR 1.11, 95% CI 1.06 to 1.16), leakage episodes (WMD -0.19, 95% CI -0.30 to -0.09), frequency (WMD -0.27, 95% CI -0.47 to -0.06) and urgency episodes (WMD -0.44, 95% CI -0.72 to -0.16) in 24 hours, all favouring fesoterodine, but those taking fesoterodine had higher risk of withdrawal due to adverse events (RR 1.45, 95% CI 1.07 to 1.98) and higher risk of dry mouth (RR 1.80, 95% CI 1.58 to 2.05) at 12 weeks.Different doses of tolterodine: The standard 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 effects of 1 mg, 2 mg and 4 mg doses were similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses at two to 12 weeks.Different doses of solifenacin: The standard recommended starting dose of 5 mg once daily was compared to 10 mg: while frequency and urgency were less (better) with 10 mg compared to 5 mg, there was a higher risk of dry mouth with 10 mg solifenacin at four to 12 weeks.Different doses of fesoterodine:The recommended starting dose of 4mg once daily was compared to 8 and 12 mg. The clinical efficacy (patient reported cure, leakage episodes, micturition per 24 hours) of 8 mg was better than 4 mg fesoterodine but with a higher risk of dry mouth with 8 mg.There was no statistically significant difference between 4 and 12 mg in the efficacy but the dry mouth was significantly higher with 12 mg at eight to 12 weeks.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 at two to 12 weeks.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 transdermal patch site at 12 weeks., 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.Between solifenacin and immediate release tolterodine, solifenacin might be preferred for better efficacy and less risk of dry mouth. Solifenacin 5 mg once daily is the usual starting dose, this could be increased to 10 mg once daily for better efficacy but with increased risk of dry mouth.Between fesoterodine and extended release tolterodine, fesoterodine might be preferred for superior efficacy but has higher risk of withdrawal due to adverse events and higher 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.

A 17-year-old female patient with pyridoxine non-responsive homocystinuria, treated with 20 g of betaine per day, developed a strong body odour, which was described as fish-like. Urinary trimethylamine (TMA) was measured and found to be markedly increased. DNA mutation analysis revealed homozygosity for a common allelic variant in the gene coding for the TMA oxidising enzyme FMO3. Without changing diet or betaine therapy, riboflavin was given at a dose of 200 mg per day. An immediate improvement in her odour was noticed by her friends and family and urinary TMA was noted to be greatly reduced, although still above the normal range.Gradual further reductions in TMA (and odour) have followed whilst receiving riboflavin. Throughout this period, betaine compliance has been demonstrated by the measurement of dimethylglycine (DMG) excretion, which has been consistently increased. Marked excretions of DMG when the odour had subsided also demonstrate that DMG was not the source of the odour.This patient study raises the possibility that betaine may be converted to TMA by intestinal flora to some degree, resulting in a significant fish odour when oxidation of TMA is compromised by FMO3 variants. The possibility exists that the body odour occasionally associated with betaine therapy for homocystinuria may not be related to increased circulating betaine or DMG, but due to a common FMO3 mutation resulting in TMAU. Benefits of riboflavin therapy for TMAU for such patients would allow the maintenance of betaine therapy without problematic body odour.

Background: Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress urinary incontinence. It is also sometimes recommended for mixed and, less commonly, urge urinary incontinence. The supervision and content of pelvic floor muscle training programmes are highly variable, and some programmes use additional strategies in an effort to increase adherence or training effects., Objectives: To compare the effects of different approaches to pelvic floor muscle training for women with urinary incontinence., 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 and CINAHL, and handsearching of journals and conference proceedings (searched 17 May 2011), and the reference lists of relevant articles., Selection Criteria: Randomised trials or quasi-randomised trials in women with stress, urge or mixed urinary incontinence (based on symptoms, signs or urodynamics). One arm of the study included pelvic floor muscle training. Another arm was an alternative approach to pelvic floor muscle training, such as a different way of teaching, supervising or performing pelvic floor muscle training., Data Collection and Analysis: We independently assessed trials for eligibility and methodological quality. We extracted then cross-checked data. We resolved disagreements by discussion. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). We subgrouped trials by intervention., Main Results: We screened 574 records for eligibility and included 21 trials in the review. The 21 trials randomised 1490 women and addressed 11 comparisons. These were: 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). In women with stress urinary incontinence, 10% of those who received weekly or twice-weekly group supervision in addition to individual appointments with the therapist did not report improvement post-treatment compared to 43% of the group who had individual appointments only (risk ratio (RR) for no improvement 0.29, 95% confidence interval (CI) 0.15 to 0.55, four trials). Looking at this another way, 90% of those who had combined group and individual supervision reported improvement versus 57% of women receiving individual supervision only. While women receiving the combination of frequent group supervision and individual supervision of pelvic floor muscle training were more likely to report improvement, the confidence interval was wide, and more than half of the 'control' group (the women who did not get the additional weekly or twice-weekly group supervision) 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.We feel there are several reasons why caution is needed when interpreting the results of the review: there were few data in any comparison; a number of trials were confounded by comparing two arms with multiple differences in the approaches to pelvic floor muscle training; there was a likelihood of a relationship between attention and reporting of more improvement in women who were not blind to treatment allocation; some trials chose interventions that were unlikely to have a muscle training effect; and some trials did not adequately describe their intervention., Authors' Conclusions: This review found that the existing evidence was insufficient to make any strong recommendations about the best approach to pelvic floor muscle training. We suggest that women are offered reasonably frequent appointments during the training period, because the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing pelvic floor muscle training with little or no supervision.

Background: Pelvic floor muscle training (PFMT) is an effective treatment for stress urinary incontinence in women. Whilst most of the PFMT trials have been done in women with stress urinary incontinence, there is also some trial evidence that PFMT is effective for urgency urinary incontinence and mixed urinary incontinence. Feedback or biofeedback are common adjuncts used along with PFMT to help teach a voluntary pelvic floor muscle contraction or to improve training performance., Objectives: To determine whether feedback or biofeedback adds further benefit to PFMT for women with urinary incontinence.To compare the effectiveness of different forms of feedback or biofeedback., Search Strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 13 May 2010) and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs or urodynamics). At least two arms of the trials included PFMT. In addition, at least one arm included verbal feedback or device-mediated biofeedback., Data Collection and Analysis: Trials were independently assessed for eligibility and risk of bias. Data were extracted by two reviewers and cross-checked. Disagreements were resolved by discussion or the opinion of a third reviewer. Data analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Intervention (version 5.1.0). Analysis within subgroups was based on whether there was a difference in PFMT between the two arms that had been compared., Main Results: Twenty four trials involving 1583 women met the inclusion criteria; 17 trials contributed data to analysis for one of the primary outcomes. All trials contributed data to one or more of the secondary outcomes. Women who received biofeedback were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received PFMT alone (risk ratio 0.75 , 95% confidence interval 0.66 to 0.86). However, it was common for women in the biofeedback arms to have more contact with the health professional than those in the non-biofeedback arms. Many trials were at moderate to high risk of bias, based on trial reports. There was much variety in the regimens proposed for adding feedback or biofeedback to PFMT alone, and it was often not clear what the actual intervention comprised or what the purpose of the intervention was., Authors' Conclusions: Feedback or biofeedback may provide benefit in addition to pelvic floor muscle training in women with urinary incontinence. However, further research is needed to differentiate whether it is the feedback or biofeedback that causes the beneficial effect or some other difference between the trial arms (such as more contact with health professionals).

Background: Patients with hamartomatous polyposis syndromes have increased risk for colorectal cancer (CRC). Although progression of polyps to carcinoma is observed, pathogenic mechanisms remain unknown. The authors examined whether familial hamartomatous polyps harbor defects in DNA mismatch repair (MMR), and assayed for somatic mutation of PTEN, a gene inactivated in the germline of some hamartomatous polyposis syndrome patients., Methods: Ten hamartomatous polyposis syndrome patients were genotyped for germline mutations. Epithelial and nonepithelial polyp DNA were assayed for microsatellite instability (MSI) and PTEN frameshift mutation. DNA MMR and PTEN protein expression were assessed in all polyps by immunohistochemistry. In addition, 99 MSI-high sporadic CRCs and 50 each of hMLH1(-/-) and hMSH3(-/-) cell clones were examined for PTEN frameshifts., Results: Twenty-five (58%) of 43 hamartomatous polyposis syndrome polyps demonstrated dinucleotide or greater MSI in polyp epithelium, consistent with hMSH3 deficiency. MSI domains lost hMSH3 expression, and PTEN expression was lost in polyps from germline PTEN patients; sporadic hamartomatous polyps did not show any of these findings. PTEN analysis revealed wild type exon 7 and 8 sequences suggestive of nonexistent or rare events for PTEN frameshifts; however, MSI-high sporadic CRC showed 11 (11%) of 99 frameshifts within PTEN, with 4 tumors having complete loss of PTEN expression. Subcloning hMLH1(-/-) and hMSH3(-/-) cells revealed somatic PTEN frameshifts in 4% and 12% of clones, respectively., Conclusions: Nondysplastic epithelium from hamartomatous polyposis syndrome polyps harbors hMSH3 defects, which may prime neoplastic transformation. Polyps from PTEN(+/-) patients lose PTEN expression, but loss is not a universal early feature of all hamartomatous polyposis syndrome. However, PTEN frameshifts can occur in hMSH3-deficient cells, suggesting that hMSH3 deficiency could drive hamartomatous polyposis syndrome tumorigenesis., (Copyright © 2010 American Cancer Society.)

Background: Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population., Objectives: To evaluate the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention., Search Strategy: We searched the Cochrane Drugs and Alcohol Group's Trial register (August 2008) ; MEDLINE (1.1950 to 6.2008) ; EMBASE (1.1974 - 8.2008); CINAHL (1.1982-6.2008); PsycInfo (1.1806-6.2008), and reference lists of articles., Selection Criteria: We sought to include randomised or quasi-randomised studies comparing any pharmacologic intervention versus other pharmacologic treatment alone or in association with psychosocial treatment, placebo, non-intervention or psychosocial intervention., Data Collection and Analysis: Two review authors independently assessed trials for inclusion in the review. Included studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified., Main Results: The search strategy identified 793 citations. Twenty-three citations were deemed relevant for full text review; an additional ten articles were retrieved through hand searching references, for a total of thirty-three articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible., Authors' Conclusions: The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality research to determine the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment program.

Background: Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population., Objectives: To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention., Search Strategy: We searched the Cochrane Drugs and Alcohol Group's Trial register (December 2007); MEDLINE (1950 to 2007); PsycINFO (1806 to 2007); EMBASE (1974 to 2007); CINAHL (1982 to 2007), Selection Criteria: We sought to include randomised or quasi-randomised studies comparing any psychosocial intervention versus pharmacological interventions or placebo or non-intervention or another psychosocial intervention for treating alcohol dependence in pregnancy., Data Collection and Analysis: Three review authors independently assessed trials for inclusion in review. Studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified., Main Results: The search strategy identified 958 citations. 17 citations were deemed relevant for full text review, an additional 9 articles were retrieved through hand searching references, for a total of 26 articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible., Authors' Conclusions: The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality randomised controlled trials to determine the effectiveness of psychosocial interventions in pregnant women enrolled in alcohol treatment programs.

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.

Coronary stent technology has rapidly evolved from a mechanical solution to abrupt vessel closure and elastic recoil following plain balloon angioplasty, to become a vector for local drug delivery and modification of coronary plaque pathophysiology. The advent of drug-eluting stents (DES) has significantly reduced restenosis, although there is increasing concern over the risk of late stent thrombosis, particularly following cessation of antiplatelet therapy. Here we consider the limitations of the current generation of DES, and review recent advances in platform, carrier, and pharmacological technology, and their place in future clinical practice.

Background: Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence. It is sometimes recommended for mixed and less commonly urge urinary incontinence., Objectives: To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments., Search Strategy: The Cochrane Incontinence Group Specialised Trials Register was searched. The date of the most recent search was 1 December 2004., Selection Criteria: Randomised or quasi-randomised trials in women with stress, urge or mixed urinary incontinence (based on symptoms, signs, or urodynamics). One arm of the trial included pelvic floor muscle training (PFMT). Another arm was a no treatment, placebo, sham, or other inactive control treatment arm., Data Collection and Analysis: Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross-checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook (Higgins 2005). Trials were subgrouped by diagnosis. Formal meta-analysis was not undertaken because of study heterogeneity., Main Results: Thirteen trials involving 714 women (375 PFMT, 339 controls) met the inclusion criteria, but only six trials (403 women) contributed data to the analysis. Most studies were at moderate to high risk of bias, based on the trial reports. There was considerable variation in interventions used, study populations, and outcome measures. Women who did PFMT were more likely to report they were cured or improved than women who did not. PFMT women also experienced about one fewer incontinence episodes per day. There were too few data to draw conclusions about effects on other outcomes such as condition specific quality of life. Of the few adverse effects reported, none were serious. The trials in stress urinary incontinent women which suggested greater benefit recruited a younger population and recommended a longer training period than the one trial in women with detrusor overactivity (urge) incontinence., Authors' Conclusions: Overall, the review provides some support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence. Statistical heterogeneity reflecting variation in incontinence type, training, and outcome measurement made interpretation difficult. The treatment effect might be greater in younger women (in their 40's and 50's) with stress urinary incontinence alone, who participate in a supervised PFMT programme for at least three months, but these and other uncertainties require testing in further trials.

Since the advent of percutaneous coronary intervention (PCI) for stenosing coronary disease, restenosis has remained a clinical problem. Despite the emergence and evolution of coronary stents, the rate of restenosis following PCI is still 10-20%, and above 50% in high risk subgroups. With increased understanding of the pathophysiology of this process, a number of potential therapeutic targets have been identified, allowing the development of novel therapies against restenosis, which can now be delivered locally using stent platforms. Some of the reported clinical trial data utilizing drug-eluting stents (DES) have produced such profound reductions in clinical and angiographic restenosis that we have been tempted to believe we are on the brink of eradicating this process completely. As the initial excitement subsides, however, there is a need to decide whether these tools will remain effective in real-world interventional practice. In this article we review the pathophysiology of the restenotic process, and the biological targets of the DES therapies currently available in clinical practice. We attempt to define clinical target populations for DES therapy, and assess the impact on outcomes thus far. We consider the advantages that newly emergent stent coatings might offer, and whether targeting specific patient subgroups with unique antiproliferative agents may provide the best chance of limiting restenosis in high risk subgroups. Finally, we consider future strategies to prevent restenosis, with a movement away from the antiproliferative approach, and toward accelerating endothelialization.

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.

Background: Proponents of therapeutic ultrasound suggest it can decrease pain by resolution of inflammation processes and reducing the pressure on pain sensitive structures by haematoma and oedema., Objectives: The objective of this review was to assess the effects of therapeutic ultrasound for treating acute perineal pain, persistent perineal pain and/or dyspareunia, following childbirth., Search Strategy: The Cochrane Pregnancy and Childbirth Group trials register, Embase, Cinahl (to May 1996), Physiotherapy Index (1985 to May 1996) and World Congress of Physical Therapy 1994 Conference Proceedings., Selection Criteria: Randomised and quasi-randomised trials comparing active therapeutic ultrasound with no treatment, placebo ultrasound, or any other 'standard' or active treatment for women with acute or persistent perineal pain and/or dyspareunia following childbirth., Data Collection and Analysis: One reviewer assessed trial quality and extracted data., Main Results: Four trials involving 659 women were included. The trials were of variable quality. Based on two placebo controlled trials, women treated with active ultrasound for acute perineal pain were more likely to report improvement in pain with treatment (odds ratio 0.37, 95% confidence interval 0.19 to 0.69). No other outcome reached significance. In one trial comparing pulsed electromagnetic energy with ultrasound for acute perineal pain, women treated with ultrasound were more likely to have bruising at 10 days (odds ratio 1.64, 95% confidence interval 1.04 to 2.60). However those treated with ultrasound were less likely to have experienced perineal pain at 10 days (odds ratio 0.56, 95% confidence interval 0.34 to 0.92) and three months (odds ratio 0.43, 95% confidence interval 0.22 to 0.84). No other outcome reached significance. Based on one trial, women treated with ultrasound for persistent perineal pain and/or dyspareunia were less likely to report pain with sexual intercourse compared with the placebo group (odds ratio 0.31, 95% confidence interval 0.11 to 0.84). None of the other outcomes measured reached significance., Reviewer's Conclusions: There is not enough evidence to evaluate the use of ultrasound in treating perineal pain and/or dyspareunia following childbirth.

When 24 cows were classified according to whether they had a better or worse energy status (defined as a plasma beta-hydroxybutyrate level below or above 15 mg/100 ml and a plasma glucose level above or below 55 mg/100 ml) the median interval between calving and the onset of cyclicity was shorter and conception rates were better for the cows with a better energy status at seven and 14 days after calving. This was not repeated when the cows' energy status was assessed as better at either 21 days after calving or at the time of service. In the same group of cows there was a positive correlation between the loss of condition score in early lactation and beta-hydroxybutyrate levels. In a further trial 15 cows fed a silage-based diet during the dry period had better conception rates and greater luteinising hormone responses to buserelin than 14 cows fed a straw-based diet. The straw-fed cows lost more weight before calving and had significantly higher non-esterified fatty acid levels. After calving both groups of cows were fed the same diet but the cows fed straw in the dry period produced less milk and lost less weight than the cows fed silage. Dry cow nutrition affected subsequent fertility and production. The non-esterified fatty acid level in the last week or two of pregnancy is suggested as a practical indication of the level of dry cow nutrition and its probable effect on productivity. No relationships were observed between plasma urea concentrations and the fertility of the cows.

A survey of the number of treatments for lameness in 21,000 dairy cows from 185 herds in the University of Edinburgh/Dalgety Spillers dairy herd health and productivity service in England and Wales showed an average incidence of cases of 25 per cent. Veterinary surgeons treated 6.3 per cent and farmers 18.7 per cent and 1.4 per cent of cows were culled because of lameness. Monthly and regional variations were recorded. An assessment of the economic effects suggested that the average annual cost in a 100 cow herd was 1175 pounds with an overall cost to British farmers of more than 35 million pounds. The economic importance is such that research into specific factors affecting foot health should be carried out. Meanwhile, a broad approach to prevention and control of lameness on farms is recommended under the general headings of management/environment, nutrition and breeding.

Twenty-two Friesian and Friesian cross Ayrshire cows and 16 first lactation heifers were paired. Twenty were injected subcutaneously with 500 mg recombinant bovine somatotropin (sometribove) and 18 with a placebo at fortnightly intervals, starting 80 (+/- 7) days after calving, through the winter of 1986-87. The cows' weights and changes in condition, milk yields, milk solids, health and fertility were recorded regularly. Compound cake was fed at a fixed stepped rate according to the number of days since the cow calved. Silage was available on an easy-feed basis. Ten cows had their daily silage intake measured. Sometribove treated cows produced on average 27.7 kg of milk per day, 4.5 kg more than the controls. Treated heifers produced 23.5 kg per day, 2.5 kg more than the controls. Milk quality was unchanged. Treated cows gained weight during the trial, but not by as much as the controls. Control heifers also gained weight but the treated heifers lost, on average, 3 kg. Local reactions at the injection site were not felt to be of welfare concern, nor was the general effect of the extra milk production. A small number of treated animals experienced mastitis and had poorer fertility but the differences were mostly not statistically significant. If bovine somatotropin should become licensed for use in Britain it is recommended that clear guidelines should be issued on the management practices necessary for economic success and for the welfare of the treated animals.

Fortnightly injections with 500 mg (1.4 ml) of recombinant bovine somatotrophin in 20 dairy cows and heifers at 80 +/- 7 days after calving resulted in increasing milk yields, compared with paired control cows, for three to four days. The advantage was maintained for a further seven to eight days with a decline occurring during the last two to three days before the next injection. The milk yield did not return to the level of the control cows, and the gap between the lactation curves widened as treatment continued, until two to three weeks after the last injection. The cows' response to treatment was greater than the response to heifers. Blood beta-hydroxybutyrate concentrations reflected the higher energy requirements of the treated animals and the weight loss of the treated heifers. Urea-nitrogen concentrations were significantly lower in the treated animals, suggesting that they utilised protein more efficiently. Treated animals had higher inorganic phosphate concentrations, although they remained within the normal ranges. Differences in calcium, magnesium, albumin and globulin concentrations were either statistically or practically not significant.