Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women.

OBJECTIVES: Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality. METHODS: We analyzed data from 5,107 women (aged 70-75 years in 1996) who answered "Have you had constipation in the past 12 months?" in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women's Health. RESULTS: Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1-3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses. CONCLUSIONS: Persistent constipation among older women is associated with poor health outcomes.

Medium-term cost analysis of breast reconstructions in a single Dutch centre: a comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps.

BACKGROUND: Free flap breast reconstruction (BR) is generally believed to be more expensive than implant BR, but costs were previously shown to level out over time due to complications and re-operations. The aim of this study was to assess the economic implications of four BR techniques: silicone prosthesis (SP), implant preceded by tissue expansion (TE/SP), latissimus dorsi transposition with or without implant (LD ± SP) and deep inferior epigastric perforator (DIEP) flap. METHODS: A prospective historic cohort study was performed to evaluate intramural medical costs in 427 patients, who had undergone BR between 2002 and 2009. Short- and medium-term complications were incorporated. In addition, 58 patients, who had recently undergone BR, participated in a questionnaire study to prospectively evaluate extramural medical and non-medical costs. Estimates of mean short- and medium-term costs are presented per patient. RESULTS: Intramural medical costs for BR and short-term complications for unilateral DIEP flaps (€ 12,848) and TE/SP reconstructions (€ 12,400) were significantly higher than those for LD ± SP reconstructions (€ 5804), which, in turn, were more expensive than SP reconstructions (€ 4731). In bilateral cases, costs of TE/SP (€ 12,723) and LD ± SP (€ 10,760) reconstructions were comparable, while DIEP flaps (€ 15,747) were significantly more expensive and SP reconstructions were significantly cheaper (€ 6784). Overall, the medium-term costs for complications and additional operations were not significantly different (€ 3017-€ 4503). Extramural medical costs and non-medical costs were approximately € 9300 per stage, regardless of technique. CONCLUSIONS: Differences in short-term costs between techniques did not level out during follow-up and SP reconstructions remained least expensive. Single-stage SP reconstructions, however, are not suitable for all patients due to high complication rates. Definite implant placement is therefore increasingly preceded by tissue expansion at more comparable costs to autologous BR. Incorporation of non-medical costs into the cost analysis would render two-stage procedures more costly than autologous BR. To achieve the optimal result, careful patient selection is critical. Only in select cases where two options are equally applicable, cost comparison becomes a valid argument for treatment selection.

[Oncoplastic surgery of the breast: a combination of oncological and plastic surgery]. / Oncoplastische chirurgie van de mamma: combinatie van oncologische en plastische chirurgie.

The term oncoplastic surgery refers to surgery on the basis of oncological principles during which the techniques of plastic surgery are used, mostly for reconstructive and cosmetic reasons. The advantage ofoncoplastic surgery for breast cancer is the possibility of performing a wider excision of the tumour with a good cosmetic result. Oncoplastic surgery is a broad concept that can be used for several different combinations of oncological surgery and plastic surgery: mastectomy and immediate reconstruction of the breast, partial mastectomy and reconstruction, excision of the tumour by reduction mammoplasty, and tumour excision followed by remodelling mammoplasty. Oncoplastic surgery requires careful preoperative planning, which is essential in all forms of breast-sparing surgery. Oncoplastic principles can easily be applied to basic breast-sparing surgery, but one can also choose to increase the possibilities of breast surgery by organising good cooperation between the oncological surgeon and the plastic surgeon.

Clinical experience of prophylactic mastectomy followed by immediate breast reconstruction in women at hereditary risk of breast cancer (HB(O)C) or a proven BRCA1 and BRCA2 germ-line mutation.

AIM: Women with a proven BRCA1 or BRCA2 germ-line mutation or with a 50% risk of carrying the mutation, have an increased risk of breast cancer. Regular surveillance, chemoprevention or prophylactic mastectomy (PM) are options to detect breast cancer at an early stage or to reduce the risk. We describe the management of women who have opted for PM, the postoperative complications of PM, especially in combination with immediate breast reconstruction (IBR), and the oncological follow-up. METHODS: The medical records of all women who underwent a PM from December 1993 to December 1999 have been reviewed with respect to management, patient characteristics, complications and oncological follow-up. RESULTS: During the study period 112 women with a median age of 38.8 years opted for a PM: 76 were germline mutation carriers. After PM, 79 women without breast or ovarian cancer in their medical history, were free of disease after 2.5 years (median). Before PM, 29 women had been treated for breast cancer, 3.9 years (median) previously; 5 of these women had developed metastatic disease by the last consultation. Before PM, 2 patients had been treated for DCIS and 2 patients for ovarian cancer. Four DCIS were found; none of these women had evidence of disease 4.0 years (median) after PM. In 59 women laparoscopic prophylactic bilateral oophorectomy (PBO) was performed; 36 simultaneously with PM and 23 separately. A total of 103 women (92%) opted for IBR. After PM, the complication rate for IBR was 21%: 11% within 6 weeks and 10% at long-term follow-up (median 3.5) after PM, including the removal of 10 prostheses. CONCLUSIONS: Women with an increased risk of breast cancer due to a genetic predisposition should be adequately informed about the different treatment options in the setting of a multidisciplinary approach. PM can simultaneously be combined with PBO and IBR. IBR can facilitate the decision to undergo a PM. PM followed by IBR has an acceptable complication rate.

A prospective study on silicone breast implants and the silicone-related symptom complex.

This cohort study prospectively evaluated the prevalence of the silicone-related symptom complex (SRSC) in relation to antinuclear antibodies (ANA) and magnetic resonance imaging (MRI) of silicone breast implants (SBI) 1 year after implantation. A total of 57 women undergoing mastectomy followed by immediate breast reconstruction (IBR) and SBI between March 1995 and March 1997 at the University Hospital Rotterdam/Daniel den Hoed Cancer Centre, were prospectively evaluated. Just before and 1 year after IBR the sera of these women were tested for the presence of ANA and they were screened for the prevalence of SRSC-related symptoms by questionnaire. All prostheses were evaluated by MRI 1 month and 1 year after IBR. Just before operation 11% of the women had a Sjögren score of more than 2, whereas 30% had such a score 1 year after IBR ( P = 0.01). One year postoperatively women had significantly more RA/Raynaud-related complaints: 21% preoperatively versus 40% 1 year after IBR ( P = 0.03). Within the undefined complaints-related group 19% had a score of 2 or more preoperatively and 33% 1 year after IBR ( P = 0.09). There were no new cases of ANA positivity 1 year after IBR. The linguine sign was seen by MRI in three implants: one 1 month after IBR and two 1 year after IBR. There was no relation to changes in SRSC expression and these MRI findings. In conclusion, 1 year after SBI implantation women had more SRSC-related complaints, especially Sjögren's and RA/Raynaud's. Moreover there was no correlation between elevated SRSC expression and changes in the presence of ANA or changes in MRI of the SBI 1 year after IBR.

Recurrent fuzzy neural network control for piezoelectric ceramic linear ultrasonic motor drive.

In this study, a recurrent fuzzy neural network (RFNN) controller is proposed to control a piezoelectric ceramic linear ultrasonic motor (LUSM) drive system to track periodic reference trajectories with robust control performance. First, the structure and operating principle of the LUSM are described in detail. Second, because the dynamic characteristics of the LUSM are nonlinear and the precise dynamic model is difficult to obtain, a RFNN is proposed to control the position of the moving table of the LUSM to achieve high precision position control with robustness. The back propagation algorithm is used to train the RFNN on-line. Moreover, to guarantee the convergence of tracking error for periodic commands tracking, analytical methods based on a discrete-type Lyapunov function are proposed to determine the varied learning rates of the RFNN. Then, the RFNN is implemented in a PC-based computer control system, and the LUSM is driven by a unipolar switching full bridge voltage source inverter using LC resonant technique. Finally, the effectiveness of the RFNN-controlled LUSM drive system is demonstrated by some experimental results. Accurate tracking response and superior dynamic performance can be obtained because of the powerful on-line learning capability of the RFNN controller. Furthermore, the RFNN control system is robust with regard to parameter variations and external disturbances.

Hybrid supervisory control using recurrent fuzzy neural network for tracking periodic inputs.

A hybrid supervisory control system using a recurrent fuzzy neural network (RFNN) is proposed to control the mover of a permanent magnet linear synchronous motor (PMLSM) servo drive for the tracking of periodic reference inputs. First, the field-oriented mechanism is applied to formulate the dynamic equation of the PMLSM. Then, a hybrid supervisory control system, which combines a supervisory control system and an intelligent control system, is proposed to control the mover of the PMLSM for periodic motion. The supervisory control law is designed based on the uncertainty bounds of the controlled system to stabilize the system states around a predefined bound region. Since the supervisory control law will induce excessive and chattering control effort, the intelligent control system is introduced to smooth and reduce the control effort when the system states are inside the predefined bound region. In the intelligent control system, the RFNN control is the main tracking controller which is used to mimic a idea control law and a compensated control is proposed to compensate the difference between the idea control law and the RFNN control. The RFNN has the merits of fuzzy inference, dynamic mapping and fast convergence speed, In addition, an online parameter training methodology, which is derived using the Lyapunov stability theorem and the gradient descent method, is proposed to increase the learning capability of the RFNN. The proposed hybrid supervisory control system using RFNN can track various periodic reference inputs effectively with robust control performance.

Motivations, satisfaction, and information of immediate breast reconstruction following mastectomy.

This study evaluated patients' motivations for, and satisfaction with, the treatment and information of immediate breast reconstruction (IBR) with a silicone prosthesis. It studied satisfaction more deeply by relating it to the quality of life, body-image and sexual functioning. Seventy-three patients who received mastectomy, followed by IBR with a subpectoral silicone prosthesis, completed a self-report questionnaire concerning their motivations for, perceived advantages of and satisfaction with IBR, the information received, quality of life, body image, and sexual functioning. Despite the fact that 50% of the reconstructions resulted in complications or complaints, 70% of the women were satisfied with the reconstruction and only 12% would never choose IBR again. Satisfaction was strongly correlated with the need for information. The higher the patient's expectations, the higher their need for information. The most common perceived advantage of IBR was the avoidance of an external prosthesis. A majority of patients were satisfied with the breast reconstruction. However, a sizeable proportion needed more information about breast reconstruction and the use of the silicone prosthesis. To avoid too high expectations more attention should be given to possible complications and the moderate cosmetic results.

Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy.

AIMS: This study evaluates the incidence of local complications after immediate breast reconstruction (IBR) following mastectomy with a subpectorally placed silicone prosthesis, with emphasis on the effect of radiation treatment on IBR. METHODS: The medical records of 100 women, who underwent a mastectomy followed by IBR with a subpectorally placed silicone prosthesis at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, between March 1990 and March 1995, were reviewed. Thirteen prostheses were implanted prior to radiation treatment, and 15 prostheses were implanted after irradiation of the chest wall. RESULTS: Early complications were seen in 15% of the IBR and were more often in irradiated women. At long-term follow-up, the most common complication was capsular contracture (21%). This occurred significantly more around prostheses placed in a previously irradiated area (P<0.0005), or which were irradiated after IBR (P=0.001). Loss of prosthesis was seen in 11 cases, and was significantly (P<0.005) more in irradiated women (n=5; 18%) compared to women who were not irradiated (n=6; 7%). CONCLUSIONS: Complications after IBR with a silicone prosthesis were more common in women who were treated with radiotherapy prior to or after IBR following mastectomy than in women who were not irradiated. In particular, capsular contracture around a prosthesis placed in a previously irradiated area was significantly increased. The use of musculocutaneous flaps, such as the transverse rectus abdominis muscle or latissimus dorsi flap, is preferable for reconstruction of previously irradiated breasts. There is no indication to remove the prosthesis before radiation therapy of the chest wall.

First evaluation study of the Dutch Working Party on silicone breast implants (SBI) and the silicone-related symptom complex (SRSC).

This cohort study evaluates the postoperative prevalence of antinuclear antibodies (ANA) in relation to symptoms related to the so-called silicone-related symptom complex (SRSC). A total of 63 women who underwent mastectomy followed by immediate breast reconstruction with a silicone implant (SBI) between Septembber 1990 and May 1995 at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, participated voluntarily in the study. Their sera were tested for the presence of antinuclear antibodies (ANA) and at the same time they were screened for the prevalence of SRSC-related symptoms by questionnaire. All patients were also examined physically. Sixteen per cent of the women were ANA positive. There was no difference in SRSC expression between ANA-positive and ANA-negative women. The lack of difference in symptom expression between the ANA-positive and ANA-negative women and the rather low complaint percentage proves that if ANA positivity is related to the SRSC, we found no evidence that patients with a SBI with a positive ANA differed from the ANA-negative patients.

Recurrent neural network control for LCC-resonant ultrasonic motor drive.

A newly designed driving circuit for the traveling wave-type ultrasonic motor (USM), which consists of a push-pull DC-DC power converter and a two-phase voltage source inverter using one inductance and two capacitances (LCC) resonant technique, is presented in this study. Moreover, because the dynamic characteristics of the USM are difficult to obtain and the motor parameters are time varying, a recurrent neural network (RNN) controller is proposed to control the USM drive system. In the proposed controller, the dynamic backpropagation algorithm is adopted to train the RNN on-line using the proposed delta adaptation law. Furthermore, to guarantee the convergence of tracking error, analytical methods based on a discrete-type Lyapunov function are proposed to determine the varied learning rates for the training of the RNN. Finally, the effectiveness of the RNN-controlled USM drive system is demonstrated by some experimental results.

An adaptive fuzzy-neural-network controller for ultrasonic motor drive using the LLCC resonant technique.

In this study an adaptive fuzzy-neural-network controller (AFNNC) is proposed to control a rotary traveling wave-type ultrasonic motor (USM) drive system. The USM is derived by a newly designed, high frequency, two-phase voltage source inverter using two inductances and two capacitances (LLCC) resonant technique. Then, because the dynamic characteristics of the USM are complicated and the motor parameters are time varying, an AFNNC is proposed to control the rotor position of the USM. In the proposed controller, the USM drive system is identified by a fuzzy-neural-network identifier (FNNI) to provide the sensitivity information of the drive system to an adaptive controller. The backpropagation algorithm is used to train the FNNI on line. Moreover, to guarantee the convergence of identification and tracking errors, analytical methods based on a discrete-type Lyapunov function are proposed to determine the varied learning rates of the FNNI and the optimal learning rate of the adaptive controller. In addition, the effectiveness of the adaptive fuzzy-neural-network (AFNN) controlled USM drive system is demonstrated by some experimental results.

Diabetic patients with foot burns.

We describe six patients with non-insulin dependent (Type 2) diabetes mellitus (NIDDM) and thermal foot injury admitted to the Burn Centre in Rotterdam. They were all male with a mean age of 56.8 (range 47-63) years. The median patients' delay before admission was 27 (range 1-56) days. Five patients needed amputation. Healing of the wounds took a mean period of 9.5 (range 2-27) months. In two patients healing of the wounds took more than 1 year; these two patients also had recurrent foot burns. Neurological evaluation in four patients confirmed severe polyneuropathy and severe loss of heat pain, warmth, and cold sensation.

The human steroidogenic acute regulatory (StAR) gene is expressed in the urogenital system and encodes a mitochondrial polypeptide.

The first enzymatic step in the biosynthesis of steroid hormones occurs in the mitochondrial inner membrane and is dependent on the mobilization of cholesterol from cellular stores. We report on the isolation of a human cDNA which encodes a mitochondrial protein called steroidogenic acute regulatory (StAR) protein, implicated in transport of cholesterol into mitochondria. Nucleotide and predicted amino acid sequence analyses indicate that the human and murine polypeptides are highly conserved, sharing 87% identity with an overall homology of 92%. Analysis of the distribution of StAR mRNA transcripts in human tissues by Northern blotting reveals several mRNA species, the most abundant of which is a 1.8 kb mRNA transcript present in testes, ovaries and kidneys. Using in vitro translated protein, we demonstrate that the StAR gene product can be efficiently imported into exogenously added mitochondria.

[Initial results of immediate reconstruction of the breast following mastectomy]. / Eerste resultaten van directe reconstructie van de borst na mastectomie.

OBJECTIVE: Evaluation of the results of immediate reconstruction after mastectomy for breast cancer by means of a silicone implant. DESIGN: Retrospective analysis. SETTING: Department of Surgical Oncology of the Dr Daniël den Hoed Cancer Centre and Department of Surgery of the Zuiderziekenhuis, Rotterdam, the Netherlands. METHOD: From September 1990 till July 1993, 37 immediate reconstructions of the breast after mastectomy were performed in 35 patients by means of a silicone implant. Indications for the treatment, consequences for further oncological treatment, additional plastic surgery, and complications of the reconstruction were evaluated. RESULTS: The indications for mastectomy and immediate reconstruction were local recurrence after breast conservative treatment (6 operations), multifocal disease (8), extensive in situ carcinoma (8), non-radically removed tumour at lumpectomy (5), anticipated poor cosmetics after breast conservative treatment (6), prophylactic ablation of the breast (2), and patient preference (1). 5 patients received adjuvant systemic chemotherapy, which could be administered without delay, and without negative influence on the result of the breast reconstruction. Additional plastic surgical treatment consisting of reconstruction of the areolar complex and correction of the breast symmetry, was performed in 5 and 3 patients respectively. In 8 of the 37 reconstructions (22%) complications were encountered. The main complications were haematoma (2), infection (4), implant removal (3), capsular contracture (2), skin necrosis (2), and luxation of the implant (1). CONCLUSION: Immediate reconstruction after mastectomy is a valuable treatment modality in breast cancer.

Use of glycerol-preserved skin in plastic surgery.

It is not always possible to effect immediate closure of wounds and patients' wounds are therefore exposed to risks of desiccation and infection. In the Plastic Surgery Department, Zuider Ziekenhuis, Rotterdam, we have used glycerolized allogeneic donor as a biological dressing in four patients; a polytrauma patient with a compound fracture of the left lower leg; a diabetic with necrotizing fasciitis; a patient with a cat bite on the lower leg, infected with Pasteurella multocida, and a child with large congenital naevi. On clinical grounds there are suggestions of a correlation between the degree of contamination and vascularization of the wound bed and graft take. Furthermore, our experience with the sandwich technique after excision of a large congenital naevus was positive.

A comparison of electric and magnetic compound action signals as quantitative assays of peripheral nerve regeneration.

The evaluation of peripheral nerve regeneration is of great interest in clinical as well as in experimental situations. However, there are few techniques that give early and quantitative information on the status of the regeneration process. If quantitative assays would be available, different surgical techniques and medications could be evaluated more accurately in relation to axonal ingrowth and functional recovery. The purpose of this study was to investigate the merits of nerve compound action signals (NCASs) recorded electrically and signals recorded with a novel magnetic recording technique. We compared the two techniques in the rabbit peroneal nerve, 2, 4, 6, and 8 weeks after a nerve reconstruction. Our conclusions are that the signals recorded with the magnetic sensor are far more reproducible and less prone to stimulus artifact than the electrically recorded signals. Furthermore, the magnetic recording shows that the number of axons that have regenerated increases with time. Previously, this could only be determined with histological studies. Other ingrowth parameters that can be quantified are the average ingrowth distance, and the variation between axons in ingrowth velocity.

[Pasteurella multocida infections: bites by dogs or cats?]. / Infecties door Pasteurella multocida: door de hond of door de kat gebeten?

Annually 50,000 to 100,000 animal bites are seen by physicians in the Netherlands. Infections of these bite wounds frequently occur. Pasteurella multocida is one of the main causes of these infections and many serious complications may occur. We present 3 patients with disturbances in wound healing after animal bites or scratches due to infection with P. multocida. In view of the high infection ratio after cat bites we advise giving amoxicillin/clavulanic acid (Augmentin) for 5 days as prophylaxis. According to the literature prophylaxis for dog bites is not necessary. However, fatal complications after dog bites due to infections with Capnocytophaga canimorsus (DF-2) support those who prefer to give antibiotics after these bites also.