Association of Constipation with Modes of Delivery: A Retrospective Questionnaire-based Study.

INTRODUCTION AND HYPOTHESIS: Pelvic floor damage can contribute to pelvic floor dysfunction, including constipation. Most studies focus on constipation during pregnancy, whereas information regarding the mode of delivery in relation to constipation is limited. We hypothesise that women with a history of vaginal delivery report constipation more often than women with a history of caesarean section. METHODS: This was a retrospective cross-sectional multicentre study conducted in the Netherlands. All included patients (n = 2,643) completed the Groningen Defecation and Fecal Continence questionnaire to assess bowel problems of the last 6 months. Parametric tests, Chi-squared, univariable and multivariable regression analyses were performed. RESULTS: Among 2,643 parous women, 2,248 delivered vaginally (85.1%) and 395 (14.9%) by caesarean section. Altogether, 649 women (24.6%) suffered from constipation. Women in the vaginal delivery group were constipated more often than women in the caesarean section group (25.5% versus 19.0%, p = 0.005). For women who had delivered vaginally, multivariable regression analysis showed an odds ratio for constipation of 1.47 (95% confidence interval, 1.109-1.938, p = 0.007). The odds ratio for constipation in women with a spontaneous perineal tear was 1.4 times higher than in women with an intact perineum (p = 0.030). Furthermore, the vaginal delivery group reported difficulties regarding bowel emptying (p = 0.048), straining (p = 0.027), incomplete defecation (p = 0.043), not able to defecate daily (p = 0.018), manually assisted defecation (p = 0.015) and had higher Renzi scores (p = 0.043) more often. CONCLUSIONS: Women in the vaginal delivery group have higher prevalences and odds ratios for constipation. Furthermore, a perineal tear during vaginal delivery increases the odds ratio for constipation.

Age-specific reference scores for the PISQ-12 on female sexual functioning in the Netherlands: a retrospective population-based survey.

BACKGROUND: Female sexual dysfunction is common in the general population, with age emerging as a significant determinant of sexual activity and functioning. AIM: To establish age-specific reference scores for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) in the general Dutch female population. METHODS: A retrospective, cross-sectional, questionnaire-based study was conducted in the Netherlands. The study population comprised 2518 Dutch-speaking women aged ≥18 years, representing a cross section of the general Dutch population. The PISQ-12 was used to assess sexual functioning in heterosexual women. The Groningen Defecation and Fecal Continence questionnaire was utilized to demonstrate demographic factors. OUTCOMES: We established age-specific reference scores for the PISQ-12 in the general Dutch population. RESULTS: Of the 2518 women, 1592 (63.2%) were sexually active and 926 (36.8%) were not. Further analysis focused on the sexually active group: we found a decrease in mean total PISQ scores, ranging from 38.34 among 18- to 34-year-olds to 36.98 among ≥65-year-olds. Older women scored lower in the behavior domain, specifically pertaining to sexual desire (P < .001) and sexual excitement (P < .001). They also had lower scores in the partner-related domain regarding partner problems of erection (P < .001) and orgasm perception (P < .001). With increasing age, negative emotional reaction scores were higher (P < .001). In the physical domain, we observed significantly different scores for pain during sexual intercourse (P < .001) and restrictions in sexual activity due to fear of urinary leakage (P < .001), with the lowest scores in the youngest group. CLINICAL IMPLICATIONS: These age-specific references scores of the PISQ-12 provide an overview of sexual functioning of a general population, which enables caregivers to assess and interpret patients' individual scores more accurately. STRENGTHS AND LIMITATIONS: We included only sexually active women in our subanalyses, potentially introducing selection bias for older women with better physical conditions. The study's strength lies in its extensive sample size, representing a cross section of the general Dutch population. Furthermore, the self-administered questionnaire approach helped minimize embarrassment and obtain realistic responses. CONCLUSION: Our study demonstrated age-specific PISQ-12 reference scores and highlighted associations between aging and diminishing scores of sexual desire, sexual excitement, erection problems, and orgasm perception, while women aged 18 to 34 years reported the lowest scores for pain during intercourse and limited sexual activity due to fear of urinary leakage.

Exploring concomitant pelvic floor symptoms in community-dwelling females and males.

OBJECTIVES: Researchers and clinicians tend to focus on one pelvic floor symptom (PFS) at the time. However, the pelvic floor acts as one functional unit, increasing the likelihood of concurrent PFS in patients with pelvic floor dysfunction. There is also a paucity of literature on the prevalence of concomitant PFS, especially in males. Therefore, we explored the occurrence of concomitant PFS in community-dwelling males and females. MATERIALS AND METHODS: This prospective observational population-based cohort study included males and females aged ≥16 years from a single Dutch municipality. Participants completed validated questionnaires on lower urinary tract symptoms (LUTS), defecation problems, sexual dysfunction, pelvic pain, and pelvic organ prolapse. Medical general practitioner records were examined. Furthermore, a randomly selected group of non-responders aged <80 years received a short questionnaire, to study response bias. RESULTS: We invited 11 724 people, among which 839 females and 566 males completed the questionnaires. Of the female participants, 286 (34.1%) reported no PFS, and 251 (29.9%) reported two or more PFS. The most prevalent PFS clusters in females were sexual dysfunction and pelvic pain, sexual dysfunction and defecation problems, LUTS and defecation problems, and LUTS, defecation problems, and pelvic pain. Of the male participants, 212 (37.5%) reported no PFS, and 191 (33.7%) reported two or more PFS. The most prevalent clusters in males were sexual dysfunction and LUTS, defecation problems and LUTS, and sexual dysfunction, LUTS, and defecation problems. CONCLUSION: A considerable overlap existed between PFS, with differences in PFS clusters between females and males. Of note, females reported pelvic pain more than males. We conclude that healthcare providers should address all PFS in males and females.

Changes in the provision of instrumental support by older adults in nine European countries during 2004-2015: a panel data analysis.

BACKGROUND: Providing support to others has been shown to be beneficial to older adults. As people age, their health and social relationships change. These changes may also relate to changes in social support provision. We examined the trajectory of instrumental support provision by older people in three European regions throughout 11 years of follow-up. We then examined the extent to which age at baseline, sex, and region (representing welfare state regime) influenced the variations in the trajectory. METHODS: Data collected from 8354 respondents who had completed at least waves 1 and 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE) was analysed. Instrumental support provision was determined from asking a single question regarding whether the respondent provided help personally for people outside their household. Region, sex, and age at baseline were the main predictors tested. We used growth modelling to address the aims of this study. RESULTS: The northern European region (Sweden and Denmark) had the highest odds ratio of instrumental support provision. The likelihood of being involved in providing instrumental support decreased by 8% annually (OR: 0.916, 95%CI: 0.893,0.940) over the 11 years of follow-up. Older respondents were less likely to provide instrumental support and their trajectories declined faster than those of the younger respondents. Sex difference in instrumental support provision was more apparent among younger-older people in the southern European region. CONCLUSIONS: Older European adults are an important source of instrumental support, especially for their families. The probability of instrumental support provision by European older adults declines over time. Age, sex, and welfare state regime predict this trajectory.

Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study).

BACKGROUND: Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed. METHODS: The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%. DISCUSSION: This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed. TRIAL REGISTRATION: Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non-inferiority randomized controlled trial.

AIMS: To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment. METHODS: We performed a multicenter non-inferiority randomized controlled trial. Women with SUI were randomly allocated to management based on a workup with or without urodynamics. The primary outcome was clinical reduction of complaints as measured with the Urogenital Distress Inventory urinary incontinence subscale (UDI-UI) at 12 months after the onset of treatment. A mean difference in improvement of less than 8 was considered non-inferior. The study was analyzed according to intention-to-treat. RESULTS: The trial was stopped prematurely because of slow recruitment. We randomly allocated 59 women to a strategy with (N = 31) or without (N = 28) urodynamics. The mean difference in improvement on the UDI-UI was 14 in favor of the group without urodynamics (48 SD ± 22 vs. 34 SD ± 22, 95% CI: -28 to -0.26), confirming non-inferiority. Addition of urodynamics did not result in a lower occurrence of de novo overactive bladder complaints compared to a workup without urodynamics (6/31 vs. 1/28; RR 5.4, 95% CI: 0.70-42). In the group allocated to urodynamics, initial surgical management was more often abandoned compared to the group not allocated to urodynamics (5/31 vs. 1/28; RR 4.5, 95% CI: 0.56-36). CONCLUSIONS: In this relatively small study, the omission of urodynamics was not inferior to the use of urodynamics in the preoperative workup of women with SUI. Women with SUI undergoing urodynamics had the risk of a choice for more prudent treatment, which seemed to result in a delay until effective treatment.

Analysis of ribosomal RNA intergenic spacer (IGS) sequences in species and populations of Gyrodactylus (Platyhelminthes: Monogenea) from salmonid fish in Northern Europe.

The intergenic spacer (IGS) region of ribosomal RNA genes was amplified and sequenced from a variety of Gyrodactylus specimens collected from wild and farmed Atlantic salmon Salmo salar, rainbow trout Oncorhynchus mykiss, and grayling Thymallus thymallus, from various locations in Northern Europe. Phylogenetic analysis of the sequences confirmed the distinction between G. salaris Malmberg, 1957 and G. thymalli Zitnan, 1960, supporting their validity as separate species. G. salaris adapted to rainbow trout are also distinct from the parasites found on Atlantic salmon, supporting the existence of a rainbow-trout form that was initially identified on the basis of morphological differences. Analysis of the IGS did not provide good resolution of different populations of G. salaris sensu stricto, but was consistent with epidemiological evidence which indicates that introduction of the parasite to Norway was recent and limited. The IGS may be helpful in distinguishing forms of G. salaris that are pathogenic to Atlantic salmon from those that are not.

Photosynthetic electron transport adjustments in overwintering Scots pine (Pinus sylvestris L.).

As shown before [C. Ottander et al. (1995) Planta 197:176-183], there is a severe inhibition of the photosystem (PS) II photochemical efficiency of Scots pine (Pinus sylvestris L.) during the winter. In contrast, the in vivo PSI photochemistry is less inhibited during winter as shown by in vivo measurements of deltaA820/A820 (P700+). There was also an enhanced cyclic electron transfer around PSI in winter-stressed needles as indicated by 4-fold faster reduction kinetics of P700+. The differential functional stability of PSII and PSI was accompanied by a 3.7-fold higher intersystem electron pool size, and a 5-fold increase in the stromal electron pool available for P700+ reduction. There was also a strong reduction of the QB band in the thermoluminescence glow curve and markedly slower Q-A re-oxidation in needles of winter pine, indicating an inhibition of electron transfer between QA and QB. The data presented indicate that the plastoquinone pool is largely reduced in winter pine, and that this reduced state is likely to be of metabolic rather than photochemical origin. The retention of PSI photochemistry, and the suggested metabolic reduction of the plastoquinone pool in winter stressed needles of Scots pine are discussed in terms of the need for enhanced photoprotection of the needles during the winter and the role of metabolically supplied energy for the recovery of photosynthesis from winter stress in evergreens.

On the evolution within the family Gyrodactylidae (Monogenea).

On the basis of six main types of protonephridial systems in the genus Gyrodactylus and results from further studies of the protonephridial systems in other gyrodactylid genera and other monogenean families, evolutionary lines within the Gyrodactylidae and the origin of the genera Ooegyrodactylus, Swingleus, Gyrdicotylus and Polyclithrum are discussed. An excretory bladder (on both sides of the body) with separate openings for the main canals of the anterior and the posterior systems, a median junction between the two anterior systems and likewise a junction between the two posterior systems, many flame bulbs and an absence of lateral flames in the main canals were found to be primitive monogenean characters. A system similar to that in the acanthocotylid larva but with secondarily evolved lateral flames in the posterior systems may have given rise to a first protogyrodactylid system, in turn giving rise to the system of Macrogyrodactylus. In a second protogyrodactylid line, the main canal of the anterior system (on both sides of the body) was connected to that of the posterior system and lateral flames were developed also in the anterior system. From this system all other described gyrodactylid systems may arise: one main line gave rise to the system of the G. (Gyrodactylus) and another to a system of G. (Mesonephrothus) type. The systems of Swingleus and Gyrdicotylus are of the latter type. Through loss of all lateral flames, the system of G. (Metanephrotus) may have evolved. Isancistrum has a system of the G. (Metanephrotus) type. From this type of system, those of Polyclithrum, G. (Neonephrotus), G. (Paranephrotus) and G. (Limnonephrotus) can be derived. The fact that the system of Ooegyrodactylus is more closely related to that of G. (Gyrodactylus) than to that of Macrogyrodactylus prompts discussion regarding the evolution of the viviparity of the family Gyrodactylidae. According to the evolutionary system presented, primitive gyrodactylids parasitise primitive fish species and the most advanced gyrodactylids parasitise the most advanced fish species. However, Anguillidae and Clupeidae may have been secondarily infected by members of G. (Metanephrotus) and G. (Neonephrotus) respectively, and Cyprinidae, Salmonidae and Esocidae may similarly have been secondarily infected by members of G. (Limnonephrotus). Isancistrum may have infected squids (Loligidae) at a medium level in the evolution within the Gyrodactylidae, while progenitors of Gyrdicotylus may have been adapted to clawed toads (Xenopidae) earlier in evolution.

Population redistribution in Sweden--long term trends and contemporary tendencies.

Long-term trends in the spatial distribution of the population of Sweden are analyzed in this study. "Two geographical levels, the national and the local, are analysed in a long term perspective, [from] 1750 until 1990. The measure of concentration used is the Hoover-index on [the] county level. Some major determinants affecting population distribution are stressed; demographic components, economic geographic conditions, socio-economic structure, attitudes and population policy. During the last few decades the traditional trend of population has been broken and one finding is that concentration and dispersion is going on simultaneously on the national and the local level."

Effects of a Short-Term Shift to Low Temperature and of Long-Term Cold Hardening on Photosynthesis and Ribulose-1,5-Bisphosphate Carboxylase/Oxygenase and Sucrose Phosphate Synthase Activity in Leaves of Winter Rye (Secale cereale L.).

The effect of a short-term (hours) shift to low temperature (5[deg]C) and long-term (months) cold hardening on photosynthesis and carbon metabolism was studied in winter rye (Secale cereale L. cv Musketeer). Cold-hardened plants grown at 5[deg]C exhibited 25% higher in situ CO2 exchange rates than nonhardened plants grown at 24[deg]C. Cold-hardened plants maintained these high rates throughout the day, in contrast to nonhardened plants, which showed a gradual decline in photosynthesis after 3 h. Associated with the increase in photosynthetic capacity following cold hardening was an increase in ribulose-1,5-bisphosphate carboxylase/oxygenase and sucrose phosphate synthase activity and 3- to 4-fold increases in the pools of associated metabolites. Leaves of nonhardened plants shifted overnight to 5[deg]C required 9 h in the light at 5[deg]C before maximum rates of photosynthesis were reached. The gradual increase in photosynthesis in leaves shifted to 5[deg]C was correlated with a sharp decline in the 3-phosphoglycerate/triose phosphate ratio and by an increase in the ribulose bisphosphate/3-phosphoglycerate ratio, indicating the gradual easing of aninorganic phosphate-mediated feedback inhibition on photo-synthesis. We suggest that the strong recovery of photosynthesis in winter rye following cold hardening indicates that the buildup of photosynthetic enzymes, as well as those involved in sucrose synthesis, is an adaptive response that enables these plants to maximize the production of sugars that have both cryoprotective and storage functions that are critical to the performance of these cultivars during over-wintering.

Mitochondrial Contribution to Photosynthetic Metabolism (A Study with Barley (Hordeum vulgare L.) Leaf Protoplasts at Different Light Intensities and CO2 Concentrations).

An oligomycin concentration that specifically inhibits oxidative phosphorylation was added to isolated barley (Hordeum vulgare L.) leaf protoplasts at various irradiances and carbon dioxide concentrations. At saturating as well as low light intensities, photosynthetic oxygen evolution was decreased as a result of the oligomycin treatment, whereas no effect was observed at intermediate light intensities. This was the same for photorespiratory and nonphotorespiratory conditions. These results were confirmed by measurements of fluorescence quenching under the same conditions. Metabolite analysis in the presence of oligomycin revealed a drastic decrease in the mitochondrial and cytosolic ATP/ADP ratios, whereas there was little or no effect on the chloroplastic ratio. Concomitantly, sucrose phosphate synthase activity was reduced. Under high irradiances, this inhibition of sucrose synthesis by oligomycin apparently caused a feedback inhibition on the Calvin cycle and the photosynthetic activity. Under low irradiances, a feedback regulation compensated, indicating that light was more limiting than the activity of regulative enzymes. Thus, the importance of mitochondrial respiratory activity might be different in different metabolic situations. At saturating light, the oxidation of excess photosynthetic redox equivalents is required to sustain a high rate of photosynthesis. At low light, the supply of ATP to the cytosol might be required to support biosynthetic reactions.

Light and temperature dependent inhibition of photosynthesis in frost-hardened and un-hardened seedlings of pine.

Needles of un-hardened and frost-hardended seedlings of Pinus sylvestris and Pinus contorta were exposed to photoinhibitory photon flux densities at temperatures between 0 and 35°C under laboratory conditions. Photoinhibition of photosynthesis was assayed by measuring oxygen evolution under saturating CO2 in a leaf disc oxygen electrode or by recording of photosystem II fluorescence induction kinetics at 77 K. It was demonstrated that frost hardening of pine did not affect the susceptibility of photosynthesis to short time (2 h) photoinhibition at 15°C. The two pine species irrespective of acclimative state were equally sensitive to photoinhibition as assayed by apparent photon yield analyses of photosynthetic oxygen evolution. Plots of the apparent photon yield of oxygen evolution vs. F v /F m revealed a non-linear relationship.In the temperature range of 15-20°C short term photoinhibition caused a loss of F v without effect on F 0 . However, photoinhibition at temperatures lower or higher caused F 0 to increase and decrease, respectively. In fact the decrease of F v v /F upon lowering the temperature was mainly caused by the temperature effect on F 0 . Besides photoinhibition causing the well established quenching of F v by increased radiationless decay somewhere in the reaction center-antenna complex, it is suggested that F 0 generally increases as a result of loss of functional reaction centers causing decreased trapping of excitation energy. However, the high temperature induced quenching of F 0 suggests that the quenching process (or processes) induced under photoinhibitory conditions is temperature dependent; i.e. it increases with the increase of temperature.In pine the photon yield of photosynthesis was much more sensitive to short term photoinhibition than was the rate of light saturated photosynthesis. This difference is explained by photosystem II and electron transport having surplus capacity relative to that of reductive carbon metabolism.

Hymenolepis diminuta: a comparison between young developing, and small, destrobilated worms in the rat intestine.

Newly in vitro excysted tapeworms of Hymenolepis diminuta (Cestoda, Cyclophyllidea), 1- to 3-day-old worms and destrobilated worms from rat intestines were investigated by means of light microscopy (LM) and scanning electron microscopy (SEM). It was found that the scolex of 1- and 2-day-old worms had shallow suckers with smooth brims, while 3-day-old and older worms, including destrobilated worms, had deep suckers with puckered brims. The posterior end of 1- and 2-day-old worms had a central cone-shaped structure not present in 3-day-old and older, or destrobilated worms. The repairing of the posterior end and the protonephridial system after excystation or destrobilation was much the same. Tissue remnants moved into the centre of the posterior end, resulting in an indentation with a pore to the exterior. The indentation and its pore became connected to the emptying canals of the protonephridial system, i.e. they developed into the excretory bladder and pore respectively.

Metabolism of Tritiated Gibberellins A(4) and A(9) in Norway Spruce, Picea abies (L.) Karst. : Effects of a Cultural Treatment Known to Enhance Flowering.

Shoots of mature grafted propagules of Picea abies (L.) Karst. metabolized [(3)H]gibberellin A(4) (GA(4)) to at least 14 acidic substances, two of which were tentatively identified by gas-liquid radiochromatography as GA(2) (possibly an artifact) and GA(34). [(3)H]GA(9) was converted into a number of metabolites, one of which was chromatographically similar to, but not identical with, GA(4). Metabolism was maximally 61 and 57% over 48 hours for GA(4) and GA(9), respectively, and was correlated with the rate of change (i.e. increase followed by decrease) in endogenous GA-like substances as shoot elongation progressed. Propagules covered with a clear plastic film, a treatment which promotes flowering, metabolized [(3)H]GA(4) more slowly than did control plants in the open. Inasmuch as a GA(4/7) mixture can also promote flowering in P. abies, the retarded metabolism of [(3)H]GA(4) may reflect the manner in which trees under plastic metabolize endogenous GA-like substances. If so, then the stimulating effect of this cultural treatment on flowering may come about through an increased level of endogenous, less polar GA-like substances.

Multi-media orientation and education programs for MEDLARS used the the Medical Information Center (MIC), Stockholm.

The Mediatron is a modified stereo-tape recorder which is designed to carry out simultaneous recording of audio-commentaries, trigger pulses for photographic slides, and digital signals from a computerized information-retrieval system. Two MEDLARS programs were produced: an orientation program and a self-instructional package. Technical procedures and experiences are briefly discussed.