Promoting urinary continence in postpartum women: 12-month follow-up data from a randomised controlled trial

A physiotherapist-delivered continence promotion program was recently implemented with postpartum women in Australia. A previous randomised controlled trial demonstrated that the program was effective in promoting pelvic floor exercises and continence at 3 months postpartum. The present study compares pelvic floor exercise frequency and continence status for women in the intervention and usual care control groups at 12 months postpartum. While there was no significant difference in continence status, women in the intervention group were more likely than those in the control group to be practising pelvic floor exercises at adequate frequencies. In turn, continued adherence to pelvic floor exercises at 12 months was predictive of continence at that time. Potential strategies for enhancing womens adherence to pelvic floor exercise regimes during and beyond the postpartum year are discussed. Editorial Comment: This is an important study that adds to the understanding of the benefit of pelvic muscle training in the reduction of postpartum urinary incontinence. It converges with the findings of several other randomized controlled trials that also demonstrate the value of this behavioral intervention. Particularly important is the partial dose/response relationship showing the lowest odds ratio of risk of UI in women doing pelvic muscle training as well as a significantly reduced risk of UI at 12 months postpartum for women reporting practicing any pelvic muscle training at all. Also noteworthy is the finding that adherence aids such as reminder dots increased the likelihood of women in the treatment group practicing pelvic muscle training. This extends evidence of the value of reminder aids demonstrated in other adherence literature such as asthma self-care regimes to specific intervention for urinary incontinence. Providers should incorporate this information into routine postpartum education.     

Beneficial effects of regular Tai Chi exercise on musculoskeletal system

This study was performed to evaluate the potential benefits of regular Tai Chi Chun (TCC) exercise on bone mineral density (BMD) and neuromuscular function in postmenopausal women. In this cross-sectional study, 99 healthy postmenopausal women, with a mean age of 55.9 ± 3.1 years and within 10 years after the menopause, were recruited; including 48 subjects who had been regularly practicing TCC exercise for more than 3h/week and 51 age- and sex-matched sedentary controls (CON). BMD was measured in the lumbar spine and proximal femur of the non-dominant leg (femoral neck, greater trochanter, and Wards triangle), using dual-energy X-ray absorptiometry (DXA). Neuromuscular function was evaluated, including magnitude of trunk bend-and-reach, quadriceps muscle strength, and single-stance time on the nondominant leg. The TCC group showed overall higher BMD at all measurement sites, with a significant difference found at the spine (7.1%), greater trochanter (7.2%), and Wards triangle (7.1%) of the proximal femur (all; P < 0.05). Functional tests revealed an average 43.3% significantly greater quadriceps strength (P < 0.01), and 67.8% significantly longer single-stance time in the TCC group as compared with the CON group (P < 0.05), as well as a greater magnitude of trunk bend-and-reach in the TCC group (P = 0.08). Bivariate linear correlation analysis showed that quadriceps muscle strength was significantly correlated with the single-stance time (r = 0.41; P < 0.01). This study revealed that regular TCC exercise may have an association with higher BMD and better neuromuscular function in early postmenopausal women.     

Assessing exercises recommended for women at risk of pelvic floor disorders using multivariate statistical techniques

Introduction and hypothesis

There is a widely held, but untested, belief that certain exercises and activities generate intraabdominal pressure (IAP) that may compromise the function of the pelvic floor muscles. Women with, or at risk of, pelvic floor disorders are advised therefore to refrain from these exercises and activities in order to theoretically protect their pelvic floor. The aim of this study was to compare IAPs generated during exercises of different types that are recommended to women as pelvic floor “safe” with those generated during the corresponding conventional exercises that women are typically cautioned against.

Methods

This was a cross-sectional cohort study. All participants were guided by a trained exercise practitioner through a series of ten exercise pairs, one version recommended to women as pelvic floor “safe” and one conventional version which women are cautioned against. IAP components were extracted from the pressure traces from a wireless intravaginal pressure sensor and used in multivariate linear regression modelling, canonical discriminant analysis, and linear mixed modelling.

Results

A total of 53 participants were recruited. After adjusting for age, body mass index and parity, there was an exercise type–version effect (p < 0.01). After taking into account all pressure components of the IAP trace, there was a significant difference in IAP between the recommended and discouraged versions of the same exercise for five of the ten exercise types. Coughing and the Valsalva manoeuvre generated IAPs that were distinct from those generated by the exercises.

Conclusions

No differences in IAPs were found between the recommended and discouraged versions of the same exercise for all exercise types. In particular, the IAPs generated during the two versions of ball rotations, lunges, core, push-ups and squats did not differ significantly. Performing the recommended pelvic floor “safe” version instead of the discouraged conventional version of these exercises may not necessarily protect the pelvic floor and vice versa.

     

Parathyroid hormone and its fragments in children with chronic renal failure

Parathyroid hormone (PTH) immunoradiometric assays (IRMA) exhibit cross-reactivity between 1-84 PTH and long carboxyl-terminal-PTH (C-PTH) molecules. C-PTH antagonizes the biological actions of 1-84 PTH and circulates in excess in chronic renal failure (CRF), partially explaining why supra-physiological PTH levels are recommended to maintain bone turnover. Furthermore, the ratio 1-84 PTH/C-PTH may be related to bone turnover. This study characterizes the 1-84 PTH/C-PTH ratio in children with varying severity of CRF and levels of PTH. Two hundred and forty-one children with CRF, managed with the aim of preventing the development of hyperparathyroidism, had PTH measured by intact IRMA and a new more specific Cyclase-Activating-PTH (CAP) IRMA. C-PTH levels were calculated by subtracting CAP-IRMA from intact IRMA. Fifty-three controls with normal renal function were also recruited. Mean intact IRMA correlated with CAP-IRMA (r=0.98), but was higher (P<0.001). The mean 1-84 PTH/C-PTH ratio was lower than controls in dialysis patients (P=0.022) and those with a glomerular filtration rate <30 ml/min per m² (P=0.033). This ratio was comparable to controls when the PTH level was normal, but was lower with PTH levels outside the normal range (P<0.01). These data suggest that CAP-IRMA gives a more accurate assessment of actual PTH levels than intact IRMA in CRF. Maintenance of normal PTH levels throughout the course of CRF permits the maintenance of a normal 1-84 PTH/C-PTH ratio, the clinical significance of which requires further investigation in children.     

Effects of voluntary pelvic floor contraction and relaxation on the urethral closure pressure

The aim of this study was to assess the effects of voluntary pelvic floor contraction and voluntary pelvic floor relaxation on the urethral closure pressure at rest. In 104 consecutive women, three urethral pressure profiles were performed: standard profile at rest, with voluntary pelvic floor contraction and with voluntary pelvic floor relaxation. A low-pressure urethra was defined as a maximum urethral closure pressure of 20 cmH₂O. The age ranged between 24 and 82 years. The maximum urethral closure pressure at rest was significantly augmented during pelvic floor contraction (mean: 18 cmH₂O). Compared with the first profile, it decreased significantly with pelvic floor relaxation (mean decrement: 8 cmH₂O). A low-pressure urethra was detected in 5 women during the first profile and in a further 11 during pelvic floor relaxation. Because of the significant influence of pelvic floor activity on the urethral closure pressure at rest, the scientific and clinical credibility of urethral pressure measurements remain questionable.Part of the results were presented at the Annual Meeting of the International Continence Society (ICS) 1999 in Denver and at national German and Swiss gynecology meetingsEditorial Comment: This very interesting study on the influence of the pelvic floor muscles on urethral pressure gives basic information about the functionality of the urethra. There is still a great lack of knowledge as we really do not know what exactly we measure when we perform an urethral pressure profile. The study points out that further investigations are necessary that should focus on the different parts of the pelvic floor muscles and their influence on the continence mechanisms. New investigative options such as magnetic nuclear resonance (MNR) and perineal ultrasound should be involved. It would have been even more interesting if the results of the performed perineal ultrasound would have been described beside the palpation of the muscle strength     

Effect of intravaginal electrical stimulation on pelvic floor muscle strength

The aim of this study was to evaluate the effect of intravaginal electrical stimulation (IES) on pelvic floor muscle (PFM) strength in patients with mixed urinary incontinence (MUI). Between January 2001 and February 2002, 40 MUI women (mean age: 48 years) were studied. Urge incontinence was the predominant symptom; 92.5% also presented mild stress urinary incontinence (SUI). Selection criteria were clinical history and urodynamics. Pre-treatment urodynamic study showed no statistical differences between the groups. Ten percent of the women in each group had involuntary detrusor contractions. Patients were randomly distributed, in a double-blind study, into two groups. Group G1 (n=20), effective IES, and group G2 (n=20), sham IES, with follow-up at 1 month. The following parameters were studied: (1) clinical questionnaire, (2) examiners evaluation of perineal muscle strength, (3) objective evaluation of perineal muscle by perineometry, (4) vaginal weight test, and (5) urodynamic study. The IES protocol consisted of three 20-min sessions per week over a 7-week period using a Dualpex Uro 996 at 4 Hz. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence, present in all patients before treatment, was reduced to 15% in G1 and 31.5% in G2 post-treatment. The subjective evaluation of PFM strength demonstrated a significant improvement in G1. Objective evaluation of PFM force by perineometer showed a significant improvement in maximum peak contraction post-treatment in both groups. In the vaginal weight test, there was a significant increase in average number of cone retentions post-treatment in both groups. With regard to satisfaction level, after treatment, 80% of the patients in G1 and 65% of the patients in G2 were satisfied. There was no statistically significant difference between the groups. There was a significant improvement in PFM strength from both effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy in treating MUI.This revised version was published online in April 2005 with corrections to the second authors name. The name of this author, Gameiro MO, was not correctly rendered in the original version.     

Comparative study of nonbridging and bridging external fixators for unstable distal radius fractures

The purpose of this study was to compare nonbridging external fixators (group NB) with bridging external fixators (group B) in the treatment for unstable distal radius fractures. The subjects consisted of 84 patients, 42 in each group. Mean patient age was 64.0 years in group NB and 59.6 years in group B. According to Saitos classification, most fractures were of the comminuted Colles type. No bone graft was made in group NB. Patients of group B showed serious reflex sympathetic dystrophy (RSD). On Saitos evaluation criteria, the proportion of patients evaluated as good or better was 100% in group NB and 95.6% in group B. This finding can be taken as evidence that group NB patients showed better results.     

Effectiveness of two conservative modes of physical therapy in women with urinary stress incontinence

Stress incontinence is the most prevalent form of female urinary incontinence and it affects approximately 5% of younger women to nearly 50% of elderly women. Women have traditionally been treated with pelvic floor muscle exercises alone or with the use of vaginal cones. A new treatment mode, vaginal balls, has been developed. The aim of this study was to compare pelvic floor muscle training with and without vaginal balls and to collect information on women's subjective feelings about the two training modes. The study was carried out as a prospective randomized clinical trial. Thirty-seven women aged 25-65 were assigned either to a pelvic floor muscle training program or to a training program using weighted vaginal balls for 4 months. Treatment outcomes were assessed by a pad-test with a standardized bladder volume, vaginal palpation, and by women's self-reported perceptions. The sense of coherence score was compared with the score for a normal population. Ninety-three percent of the women completed the study. Both training modes were effective in reducing urinary leakage: with vaginal balls (P < 0.0001) and without (P < 0.019); and increasing pelvic floor muscle strength: with vaginal balls (P < 0.0039) and without (P < 0.0002). However, the reduction of urinary leakage after four months of exercise in the training group with vaginal balls was significantly better (P < 0.03) than the results in the group training with pelvic floor muscle exercises alone. The study found the weighted vaginal balls to be a good alternative for training pelvic floor muscles in women with stress urinary incontinence.     

Pelvic floor rehabilitation

Pelvic floor disorders can be improved by various methods of conservative treatment. Urogynecologic rehabilitation involves pelvic floor physiotherapy, functional electrical stimulation and biofeedback. Recent urodynamic studies have revealed obstetric risk factors, and restoration of pelvic floor musculature after vaginal deliveries is essential. It would appear that urogynecologic rehabilitation should also be routinely prescribed during the months preceding some surgical procedures. Biofeedback has been used successfully in urologic disorders such as instability and enuresis. It is probably the most efficient therapy for learning perineal blockage at stress, which gives the patient functional control of the pelvic floor muscles during daily activities. Functional electrical stimulation, either on an outpatient basis or as a home program, is a practical and successful method for improving or curing incontinence. Physiotherapy has to be recommended more frequently to young nulliparous women as a preventive measure and to mothers after childbirth.     

Comparison of spine and femur reference data in native Chinese women from different regions of China

The aim of this study is to explore the differences of BMD reference curves at various skeletal sites among Chinese women from different regions of China and to investigate the feasibility of establishing a unified national BMD reference database for Chinese women. We measured BMD at the posteroanterior (PA) lumbar spine, femoral neck, trochanter and Wards triangle by dual-energy X-ray absorptiometry bone densitometer in 3,422 Changsha women of South Central China, aged 20–84 years. The documented BMDs of reference populations of women in all other areas included Shanghai ( n =2,111) and Nanjing ( n =3,174) in the East, Shenyang ( n =1,213) in the Northeast, Kunming ( n =523) in the Southwest, Chongqing ( n =811) in the Midwest and Xian ( n =1,320) in the Northwest. We adopted the cubic regression as the fitting model for reference curves of BMD that varied with age, conducted conversions of BMD measured by various bone densitometers from different manufacturers and compared the differences between standardized BMD (sBMD) reference curves and combined ones for women from different areas. Our results revealed that by comparing variances in women from different areas, the average variances of non-standard BMD were 0.8–30.8% at the PA spine, 0.7–24.5% at the femoral neck, 0.6–29.9% at the trochanter and 1.1–54.7% at Wards triangle, while average variances of sBMD either significantly decreased or disappeared (0.8–3.9% at the PA spine, 0.7–8.6% at the femoral neck, 0.6–8.3% at the trochanter and 1.1–29.9% at Wards triangle). The sBMD reference curves were highly positive-dependent with combined ones ( r =0.913–0.999, P =0.000). At the PA spine and trochanter, the effect of combined sBMD curves presented well in women from different areas, except for those from Shanghai at the PA spine and Shenyang at the trochanter, indicating that sBMD curves were significantly different from pooled ones; at the femoral neck and Wards triangle, the effect of combined sBMD reference curves was poor, indicating that sBMD curves demonstrated significant differences from pooled ones in women from a majority of these areas. We conclude that, in high density population areas, sBMD reference curves showed no significant geographic differences in women from various regions. In women from different areas, sBMD reference curves present good pooled results at the PA spine and trochanter. The less ideal combining effect of the sBMD curves at both femoral neck and Wards triangle might be caused by the intrinsic differences from the different measuring instruments.     

Periprosthetic fractures around cementless hydroxyapatite-coated femoral stems

We studied 14 periprosthetic femoral fractures out of a series of 619 hydroxyapatite coated hip implants and compared the outcome to published treatment algorithms using the Vancouver classification. There were five type A fractures, six B1, two B2, and one type B3 fracture. All but one type A fractures were treated conservatively. Compared with the Vancouver classification, we observed a different fracture type in the type B fractures. No fractures at the tip of the stem were seen, as in cemented implants. Three B1 fractures were treated operatively due to fracture displacement, and three were treated conservatively. The B2 and B3 fractures were managed with long, uncemented, revision stems because of a disrupted bone–prosthesis interface. All fractures healed well. This study confirms that the modified algorithm of management of periprosthetic fractures, using the Vancouver classification, is a simple, reproducible, classification system for uncemented prostheses. Conservative treatment is a valid option if the implant is stable whilst surgical intervention is mandatory if the implant is loose.

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Résumé Nous avons étudié 14 fractures fémorales péri prothétiques dans une série de 619 implants de la hanche recouverts dhydroxyapatite et nous avons comparé le résultat à lalgorithme de traitement utilisant la classification de Vancouver. Il y avait cinq fractures de type A, six de type B1, deux de type B2 et une de type B3. Toutes les fractures de type A, sauf une, ont été traités dune manière conservatrice. Comparé à la classification de Vancouver nous avons observé un type de fracture différent dans le type B. Aucune fracture à lextrémité de la tige na été vue comme dans les implants cimentés. Trois fractures B1 ont été opérées à cause du déplacement et trois a été traité dune manière conservatrice. Les fractures B2 et B3 ont été traités avec des tiges longues de révision, sans ciment, à cause dune interface os-prothèse interrompu. Toutes les fractures ont consolidé. Cette étude confirme que lalgorithme modifié de gestion des fractures péri prothétiques, en utilisant la classification de Vancouver, est un système de classification simple, reproductible, pour les modalités du traitement avec des implants sans ciment. Le traitement conservateur est une option valable en cas dimplant stable, cependant quen cas dimplant descellé lintervention chirurgicale est obligatoire.

     

Prognosis factors in incisional hernia surgery: 25 years of experience

Background Incisional hernia underwent a change from conventional techniques to mesh implantation. The relevance of different factors, like operative technique, mesh material, and patient-related parameters concerning the outcome following mesh repair, are still under debate.Methods In a comparative retrospective study of 421 incisional hernia operations on 348 patients, we investigated 241 Mayo procedures and 180 mesh repairs over a 25-year period. In addition to the quality of life following mesh implantation, the prognostic relevance of demographic, preoperative and intraoperative parameters, surgical technique, mesh material, and the surgeons experience were analysed, both in a univariate and multivariate manner.Results With a mean follow-up of 9.7±8.8 years, the total recurrence rate following Mayo overlap was 37%, in contrast to 15% after mesh implantation (P=0.001). Mesh size was the only significant prognostic factor concerning quality of life following mesh implantation, and 86% of the patients with mesh repair were satisfied. The complication rate was determined significantly by patients risk factors, size of hernia, operative technique, and the surgeons experience, whereas the rate of recurrences was significantly influenced by the parameters obesity (BMI>25), size of hernia, and surgical experience. The recurrence rate decreased significantly with surgeons experience—a minimum of 16 mesh repairs led to a recurrence rate of less than 10%. Conclusions Only the mesh repair revealed acceptable recurrence rates with high patient comfort. From a surgical point of view, the most important prognostic factor following mesh repair is the surgeons experience.This paper was presented to the American Hernia Society Congress in Orlando, Fla., USA, on Feb. 26, 2004.     

Postpartum pelvic floor conditioning using vaginal cones: Not only for prophylaxis against urinary incontinence and descensus

Seventy-one women were examined 6–8 weeks after spontaneous delivery by pelvic floor (PF) palpation, inspection, manometry and gravimetry. Re-examination was performed in the same way after 4–6 weeks of daily cone training. Control groups included 20 women prior to and after conventional puerperal exercises, and 8 nulliparae prior to and after the same cone training, using a five-cone set. The number of puerperae not capable of voluntary PF contraction declined from 34% before to 6% after training. Optimum initial and post-training responses were exhibited by all nulliparae. Differences between cone and conventional exercise groups were of minor importance. Contractility increased from 5 to 10 mmHg on average in puerperae and from 15 mmHg to 21 mmHg in nulliparae. Cone nos. 1–3 were most frequently required at the beginning of training, and nos. 3–5 towards the end. Cone training works well as an alternative or complement to conventional postpartum exercises, and may therefore be recommended especially to puerperae who are not capable of holding vaginal cones of 20–70 g 6 weeks after delivery.Editorial commentThe investigators set out to show that vaginal cones can be used for postpartum pelvic floor conditioning, and their results do indeed indicate an improvement in pelvic floor strength based on the speculum lift test, manometry and cone holding. Unfortunately, the study does not answer, and was not designed to answer, whether the use of vaginal cones is better than, equal to or worse than pelvic floor exercises for reconditioning the pelvic floor after vaginal delivery. To answer this question requires randomization, blinding and appropriate control groups (i.e. postpartum patients who do not perform any type of exercise of the pelvic floor).     

The Value of Cloquet’s Node in Predicting Melanoma Nodal Metastases in the Pelvic Lymph Node Basin

Background: A selection of melanoma patients with groin metastases can benefit from a pelvic (iliac/obturator) lymph node dissection in addition to the infrainguinal dissection. However, there are no reliable criteria to determine which patients may benefit from such an inguinal-pelvic lymphadenectomy.Methods: In 142 patients (group A) out of a review of 214 groin dissections performed between 1980 and 1994, the tumor status of Cloquets node was traced retrospectively. In 52 additional patients (group B), the status of Cloquets node was registered prospectively. The number of positive lymph nodes and the total numbers of retrieved nodes were recorded as well. All patients underwent a combined therapeutic inguinal-pelvic lymph node dissection between January 1995 and June 1999 in a tertiary referral center.Results: Cloquets node was free of disease in 18 of 39 patients with involved pelvic nodes in the retrospective study (sensitivity, 54%; negative predictive value, 83%). In the prospective study, 9 of the 20 patients with involved pelvic nodes had a tumor-free Cloquets node (sensitivity, 55%; negative predictive value, 78%). Additional immunohistochemical staining of Cloquets node resulted in a sensitivity of 65%. In the combined group A&B, the number of positive nodes in the inguinal region (cutoff point more than three nodes) had a sensitivity of 41% and a negative predictive value of 78% to determine the pelvic nodal status. When we combined the number of positive inguinal nodes and Cloquets node in group A&B, the best sensitivity was 56% and the best negative predictive value was 82%.Conclusions: Cloquets node has a low sensitivity to predict the pelvic nodal tumor status. This was barely improved when we accounted for the number of positive inguinal nodes. Groin lymph node dissections should encompass the iliac and obturator compartments in patients with palpable inguinal node metastases.     

Pelvic floor reeducation and body posture correction for treatment of female urinary incontinence: Results of comprehensive pre- and post-treatment urodynamic testing

Of the conservative treatment modalities for stress urinary incontinence in females, the effectiveness of electric pelvic floor stimulation and exercise programs for reeducation of pelvic floor muscles are generally accepted and recognized. This prospective study reports on the analysis of subjective and objective pre- and post-treatment parameters in 12 selected female patients with stress incontinence who were enrolled in a physiotherapeutical training program consisting of acute intrarectal electrostimulation, pelvic floor exercises, and body posture correction (Mensendieck). Patients' symptom scores, performance status of pelvic floor muscles, body posture alterations as well as standard urodynamic parameters (maximal urethral closing pressure, functional urethral length, and maximum cystometric capacity), and telemetric ambulatory urodynamic parameters (pad-weighing test, urethral relaxations) were analyzed. This study shows the advantageous effect of pelvic floor reeducation and body posture correction for the treatment of female low-urethral-resistance urinary incontinence. A remarkable finding was the coalescence of genuine stress incontinence, proven on standard urodynamic investigation, and urethral instability on telemetric ambulatory urodynamic investigation in 10 of 12 patients (83%). This was very well treated by the training program. Pathophysiology of low-urethral-resistance urinary incontinence and the mode of action of the training program are discussed. © 1992 Wiley-Liss, Inc.     

The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males

The purpose of this study was to undertake a critical review of the potential role of magnetic resonance imaging (MRI) in the evaluation of low back pain (LBP) and to determine if there were differences in the MRI appearances between various occupational groups. The study group, 149 working men (78 aged 20-30 years and 71 aged 31–58 years) from five different occupations (car production workers, ambulance men, office staff, hospital porters and brewery draymen), underwent MRI of the lumbar spine. Thirty-four percent of the subjects had never experienced LBP Twelve months later, the examination was repeated on 89 men. Age-related differences were seen in the MRI appearances of the lumbar spine. Disc degeneration was most common at L5/S 1 and was significantly more prevalent (P < 0.01) in the older age group (52%) than in the younger age group (27%). Although LBP was more prevalent in the older subjects there was no relationship between LBP and disc degeneration. No differences in the MRI appearance of the lumbar spine were observed between the five occupational groups. Overall, 45% had abnormal lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). There was not a clear relationship between the MRI appearance of the lumbar spine and LBP. Thirty-two percent of asymptomatic subjects had abnormal lumbar spines and 47% of all the subjects who had experienced LBP had normal lumbar spines. During the 12-month follow-up period, 13 subjects experienced LBP for the first time. However, there was no change in the MRI appearances of their lumbar spines that could account for the onset of LBP. Although MRI is an excellent technique for evaluating the lumbar spine, this study shows that it does not provide a suitable pre-employment screening technique capable of identifying those at risk of LBP.     

Dynamic assessment of pelvic floor function in women using the intravaginal device test

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the ² test and the response/ operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (X²=58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.EDITORIAL COMMENT: In 1988, Peattie and Plevnick introduced the use of weighted vaginal cones to exercise the pelvic floor muscles and treat stress urinary incontinence [1]. Contreras-Ortiz and Nuñez build on this earlier work, using a similar technique to assess pelvic floor muscle function and integrity. Specifically, pelvic floor function is assessed by a combination of digital palpation of the pubococcygeus muscle at rest and during contraction; pelvic floor integrity is assessed by the patient's ability to retain a weighted cone vaginally for 1 minute. Scoring of these two parameters can then be objectively followed for therapeutic response to treatment for urinary incontinence or pelvic relaxation. Many of us forget to palpate the pubococcygeus muscle at rest and during an elicited contraction during baseline or follow-up examination. As this study indicates, simple assessment of pelvic floor function and integrity is possible, and should be used both clinically and in research.     

Comparison between the Klemetti index and heel DXA BMD measurements in the diagnosis of reduced skeletal bone mineral density in the elderly

Osteopenia/osteoporosis affect many elderly people and might not be detected until symptoms of fractures occur. Early detection of osteopenia/osteoporosis is important and would allow preventive measures and treatment. Access to screening for osteopenia/osteoporosis is often limited, whereas panoramic radiography is commonly used in dentistry. The aim of this study was to determine the validity of the Klemetti index (KI), measured on panoramic radiographs, in the diagnosis of osteopenia/osteoporosis as defined by a bone mineral density (BMD) measurement below –1.5 standard deviations (SDs) of a community based sample. In total, 211 consecutive participants (102 men and 109 women) 60–96 years in the SNAC–Blekinge study (Swedish National Study on Ageing and Care) underwent bone densitometry [by dual-energy X-ray absorptiometry (DXA)] of both heels. A panoramic radiograph was taken of each participant, and mandibular cortex on a panoramic radiograph was classified as 0 or normal (even and sharp endosteal margin), 1, moderately eroded (evidence of lacunar resorption or endosteal cortical residues), or 2, severely eroded (unequivocal porosity). From logistic regression, the odds ratio of having a BMD measurement below –1.5 SD was 8.04 (95% CI 2.39 to 27.12, P<0.001) in the osteopenic (KI category 2), compared with the normal group (KI categories 0 and 1). Receiver operating characteristic (ROC) curve analysis was used to measure the validity of the KI indicating osteopenia (KI category 2) in predicting reduced BMD. This point provided a sensitivity of 50% and a specificity of 89%. Positive and negative predictive values were 21% and 97%, respectively. There were 87% correctly classified subjects. The area under the ROC curve was 0.64. The present study demonstrated that a negative finding (KI category <2) is highly predictive of the absence of osteopenia/osteoporosis as defined by the DXA measurements.     

Perceived self-efficacy as a predictor of outcome of pelvic muscle exercises in the treatment of urinary incontinence

Perceived self-efficacy (a person's confidence in her ability to perform a specific behavior in a specific situation) is a powerful mediator of health behavior changes in many areas. Despite the increasing attention paid to behavioral therapies for urinary incontinence, perceived self-efficacy has been largely overlooked. This preliminary study was conducted to evaluate the relationship between perceived self-efficacy and the treatment outcome of pelvic muscle exercises. Seventy-one women enrolled in a study assessing the outcome of a 3-month course of pelvic floor muscle exercises completing a self-efficacy questionnaire, which was administered at baseline and 3 weeks into treatment. Sixty-three of the women completed the questionnaire at 3 weeks. The primary outcome measure was number of incontinent episodes per day, as reported on a 3-day voiding diary. We defined improvement as 50% reduction in the number of incontinent episodes. There was a negative relationship between self-efficacy expectations at baseline and treatment outcome (r=–0.402). There was a trend toward a relationship between increases in self-efficacy between baseline and 3 weeks and improved treatment outcome (r=0.312,P<0.07). We examined behavioral factors which might affect exercise continuation, and found that both inaccessibility for telephone follow-up calls and incompletely recorded baseline voiding diary were associated with a higher dropout rate. Our preliminary results, then, are mixed, as we found no relationship between high initial self-efficacy and treatment outcome, but did find a possible association between increases in self-efficacy perception and treatment outcome. Self-efficacy may be another piece in the puzzle of how to improve outcome for non-surgical incontinence treatments, but it needs more evaluation. Our research suggests that healthcare providers should not be reticent to recommend a course of pelvic muscle exercises for those patients who express poor perceived self-efficacy at the outset of treatment. In addition, an incomplete or partially completed voiding diary should serve as a warning that a patient may be a suboptimal candidate for behavioral therapy.EDITORIAL COMMENT: This pilot study examines a new aspect of pelvic floor exercises in treating urinary incontinence, specifically how a patient's perception of ability to perform pelvic floor exercises influences the outcome of an exercise program designed to treat incontinence. Perceived self-efficacy has long been known to be an important issue in behavioral therapy for other conditions, such as smoking cessation, weight loss and pain control. Although this study lacks sufficient numbers to be statistically powerful, the results are interesting and hopefully will entice others to further investigate the relationship between perceived self-efficacy and behavioral treatment outcome.     

Integrin laminin receptors and breast carcinoma progression

This review explores the mechanistic basis of breast carcinoma progression by focusing on the contribution of integrins. Integrins are essential for progression not only for their ability to mediate physical interactions with extracellular matrices but also for their ability to regulate signaling pathways that control actin dynamics and cell movement, as well as for growth and survival. Our comments center on the 6 integrins (61 and 64), which are receptors for the laminin family of basement membrane components. Numerous studies have implicated these integrins in breast cancer progression and have provided a rationale for studying the mechanistic basis of their contribution to aggressive disease. Recent work by our group and others on mechanisms of breast carcinoma invasion and survival that are influenced by the 6 integrins are discussed.