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Aim: The aim of this work was to perform a long‐term evaluation of a randomized trial focusing on functional aspects after excisional haemorrhoidectomy with a minimum follow‐up of 9 years. Method: A questionnaire‐based study including patients operated on for haemorrhoids in Sweden between 1999 and 2003. A total of 225 patients were randomized to Milligan's or Ferguson's operation. Twenty‐six patients had died and 151 (76%) participated after a median follow‐up of 10.7 years (range 9.2–12.6 years). Results: Seventy‐seven patients were in the Milligan group and 74 in the Ferguson group. Forty‐eight (32%) reported recurrence. Anal bleeding was reported in 80% at baseline but in 28% at long‐term follow‐up (P < 0.0001). At baseline, 49% had spontaneous anal pain and 25% pain at defaecation. At follow‐up, these figures were 17% and 11%. At follow‐up, 19% described a sense of anal stenosis. At baseline, soiling was reported in 51% but in 20% at long‐term follow‐up (P < 0.001). Nineteen per cent used pads preoperatively and 6% at follow‐up (P < 0.0001). Straining at defaecation was reported by 35% at baseline. At follow‐up, this figure was 25% (P = 0.055). Conclusion: Symptoms associated with haemorrhoids were reduced at long‐term follow‐up. The most common problems were perceived recurrence and a sense of anal stenosis. [ABSTRACT FROM AUTHOR]

For centuries, rivers have experienced massive changes of their hydromorphic structures due to human activities. The Danube River, the second largest river in Europe, is a case in point for long‐term societal imprint. Resulting human‐induced pressures are a key issue for river management, aiming to improve the ecological conditions and guarantee the provision of ecosystem services. As the most international river basin in the world, the management of the Danube is particularly challenging and needs a well‐organized cooperation of 19 nations. The recent river basin management plan has identified pollution and hydromorphological alterations as most pressing problems, but it has also acknowledged newly emerging issues. In this article, we present 3 specific examples of highly relevant issues for the future river basin management of the Danube: (a) long‐term impacts in the catchment such as changes in flood patterns and potential ecological consequences; (b) complex feedback loops linking the spread of neozoa with intertwined stressor responses due to river engineering for different purposes; and (c) linkages between different assessment approaches based on European legal frameworks to analyse the specific pressures at different spatial scales. These examples highlight the need for a more integrated approach in future Danube River Basin management schemes. Furthermore, large‐scale effects such as climate change and interactions of multiple pressures need to be addressed in future management to increase resilience of the river system and to allow a sustainable ecosystem‐based management of rivers. [ABSTRACT FROM AUTHOR]

Aim Treatment of Crohn's anal fistula remains challenging and little is known about factors associated with healing. The aim of this study was to assess the rate of healing after surgical treatment and analyse clinical variables related to healing. Method A total of 119 patients [63 women, mean age 36 (±13.7) years] with histopathologically verified Crohn's disease underwent a surgical procedure for anal fistula at four main referral centres in Sweden, January 1998 to December 2009. Baseline and treatment-related variables were recorded and analysed for correlation with fistula healing at a final follow-up after a mean of 7.2 (median 7.1, 1.0-17.5) years. Results Of the 119 patients 62 (52%) were healed at final follow-up. Fourteen healed after one procedure and the remaining 48 healed after a further median of 4.0 (2-20) procedures. Ten (8%) patients were subjected to a proctectomy. Final healing was more common in patients operated with a procedure aiming at eradicating the fistula (P = 0.0001), without proctitis (P = 0.02) and a shorter duration of Crohn's disease (P= 0.0019). Conclusion Long-term healing of a Crohn's anal fistula can be expected in about half of the patients, usually after repeated surgical treatment. The probability for cure was higher when a curative operation was performed in a patient without proctitis and with a shorter duration of Crohn's disease. An attempt to close a Crohn's anal fistula is thus often worthwhile. [ABSTRACT FROM AUTHOR]

Background Sacral nerve stimulation is an established treatment for fecal incontinence and initial reports describe successful results also in subjects with chronic constipation. Methods Consecutive patients with slow transit or outlet obstruction type constipation were offered external stimulation through a test electrode inserted in a sacral foramen during a 3-week period. The symptomatic evaluation was based on the number of bowel movements and a validated obstructed defecation score ( ODS). A permanent implant was performed provided an overall 50% decrease in symptoms was observed. Key Results In total, 44 patients with chronic constipation were treated with a 3-week test stimulation. Fifteen experienced a 50% reduction of symptoms and received a permanent implant. Four of the 15 with permanent implants were explanted during the course of the study. Five subjects (11% of original group) reported sustained symptom relief at final follow-up after a mean of 24 months (range 4-81). Mean ODS score did not change during the treatment. Patients with predominantly slow transit constipation or outlet obstruction did not differ concerning success rate. Conclusions & Inferences Sacral nerve stimulation has limited efficacy in unselected patients with chronic constipation and cannot be recommended for treatment on routine basis. [ABSTRACT FROM AUTHOR]

Background Injectable bulking treatment for fecal incontinence ( FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer ( NASHA Dx) on FI symptoms. Methods In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score ( CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated. Key Results Successful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months ( p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort. Conclusions & Inferences Submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years. [ABSTRACT FROM AUTHOR]

Aim Ligation of the intersphincteric fistula tract ( LIFT) is a novel sphincter-preserving technique for anal fistula. This pilot study was designed to evaluate the results in patients with a recurrent fistula. Method Seventeen patients [nine men; median age 49 (range, 30-76) years] with a recurrent trans-sphincteric fistula were treated with a LIFT procedure between June 2008 and February 2011. All were followed prospectively for a median of 16 (range, 5-27) weeks with clinical examination. Fifteen followed for 13.5 (range, 8-26) months by clinical examination also had three-dimensional (3 D) anal ultrasound. Results The duration of the procedure was 35 (range, 18-70) min. One patient developed a small local haematoma and one had a subcutaneous infection, but otherwise there was no morbidity. At follow up, 11 (65%) patients had a successful closure, two (12%) had a remaining sinus and four (23%) had a persistent fistula. The incidence of persistent or recurrent fistulae at 13.5 months was six (40%) of 15 patients. No de novo faecal incontinence was reported. Conclusion LIFT is a safe procedure for patients with recurrent anal fistula, with healing at short-term and medium-term follow-up comparable with or superior to that of other sphincter-preserving techniques. Larger studies with a longer follow up are needed to define the ultimate role of LIFT in patients with recurrence. [ABSTRACT FROM AUTHOR]

Aim Perineal wound sepsis is a common problem after abdominoperineal resection of the rectum (APR), with a reported incidence of 10-15% in previously non-irradiated patients, 20-30% in patients given preoperative radiation and 50% among patients submitted to preoperative radiation combined with chemotherapy. The local application of gentamicin-collagen was evaluated to determine whether its use in the perineal wound reduced risk complications and had an effect on cancer recurrence. Method In this prospective multicentre (seven hospitals) randomized controlled trial, 102 patients undergoing APR due to cancer or benign disease were randomized into two groups including surgery with gentamicin-collagen (GS+, n = 52) or surgery without gentamicin-collagen (GS−, n = 50). Patients were followed at 7, 30 and 90 days and at 1 and 5 years. Results There were no statistically significant differences between the two groups regarding perineal wound complications, infectious or non-infectious, or cancer recurrence. Conclusion There was no statistically significant effect on perineal wound complications or cancer recurrence following the local administration of gentamicin-collagen during APR. [ABSTRACT FROM AUTHOR]

In the article, a new approach is presented utilizing artificial neural networks for uncertain time-dependent structural behavior. Recurrent neural networks (RNNs) for fuzzy data can be trained by uncertain experimental data to describe arbitrary stress-strain-time dependencies. The benefit is a generalized formulation, which can be applied to describe the behavior of several materials without definition of a specific material model. Model-free material descriptions can be used as numerical efficient material formulations within the finite element method. To perform fuzzy or fuzzy stochastic finite element analyses, a new approach is introduced. An -level optimization is utilized for signal computation and training of RNNs for fuzzy data. The applicability is demonstrated by means of examples. [ABSTRACT FROM AUTHOR]

Due to reduced evaporation and diffusion of water molecules containing heavier isotopes, leaf water possesses an elevated 18O or 2H steady-state content. This enrichment has been exploited in plant physiology and ecology to assess transpiration and leaf water relations. In contrast to these studies, in this work the 2H content of the medium of hydroponically grown Arabidopsis thaliana was artificially raised, and the kinetics of 2H increase in the aerial parts recorded during a short phase of 6–8 h, until a new equilibrium at a higher level was reached. A basic version of the enrichment models was modified to establish an equation that could be fitted to measured leaf 2H content during uptake kinetics. The fitting parameters allowed estimation of the relative water flux q leaf into the Arabidopsis rosette. This approach is quasi-non-invasive, since plants are not manipulated during the uptake process, and therefore, offers a new tool for integrated analysis of plant water relations. The deuterium tracer method was employed to assess water relocation in Arabidopsis pip2;1 and pip2;2 aquaporin knockout plants. In both cases, q leaf was significantly reduced by about 20%. The organ and cellular expression patterns of both genes imply that changes in root hydraulic conductivity, as previously demonstrated for pip2;2 mutants, and leaf water uptake and distribution contributed in an integrated fashion to this reduced flux in intact plants. [ABSTRACT FROM AUTHOR]

Objective Colonic transit studies are used to diagnose slow transit constipation (STC) and to evaluate segmental colonic transit before segmental or subtotal colectomy. The aim of the study was to compare a single X-ray radio-opaque marker method with a scintigraphic technique to assess total and segmental colonic transit in patients with STC. Method Thirty-one female patients (median age 46 years) with severe constipation and a prolonged or borderline prolonged colonic transit time on radio-opaque marker study were included in the study. They were subsequently investigated with 111Indium-DTPA colonic transit scintigraphy, with a median time between the investigations of 4(range 1–27) months. Normal values of healthy female controls were used for comparison. Results There was no difference between the two methods in terms of prolonged or normal total colonic transit time. Twenty-nine of 31 female patients had a prolonged transit time only in one or two segments on the marker study. On scintigraphy, the transit time was prolonged for patients in the left ( P < 0.05 to P < 0.001), but not in the right colon. With respect to prolonged or normal segmental transit time, there was a significant difference between the two methods only in the descending colon ( P = 0.02). However, the results varied considerably for individual patients. Conclusion Segmental colonic delay was a common finding. The two methods gave similar results for groups of patients, except in the descending colon. The variation of the results for individuals suggests that a repeated transit test may improve the assessment of total and segmental transit. [ABSTRACT FROM AUTHOR]

Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side-effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right- or left-sided delay.Twenty-three constipated patients (19 women, mean age 50 years) with slow colonic transit on radio-opaque marker studies and 13 healthy individuals (11 women, mean age 46 years) were studied. All subjects were examined with oral111Indium-DTPA scintigraphy. The scintigraphic results for patients and controls were presented as geometric centre of radioactivity and percent activity over time in the right, the left and the recto-sigmoid colon. The inter-observer variation in the interpretation of the scans was also evaluated.There was no difference in transit time between the groups of patients and controls in the right colon whereas the patients had a significant delay in the left colon (P < 0.05). Two patients had a marked delay in the right colon followed by relatively rapid transit in the left colon. The inter-observer correlation was good comparing the right, the left and the recto-sigmoid colon (r =0.58–0.98,P < 0.01–0.001).The results indicate that colonic scintigraphy with oral111Indium-DTPA may help to select patients for a left or, in a few cases, a right hemicolectomy for slow transit constipation. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate anorectal physiology in relation to clinically defined subgroups of patients with idiopathic constipation and to analyse relationships between anorectal physiology and rectal evacuation. One hundred consecutive patients with idiopathic constipation were clinically categorized as slow transit ( n = 19), outlet obstruction ( n = 52) and a group with mixed symptoms ( n = 29). They were examined by recording anal pressures and also rectal volumes in response to stepwise increases in rectal pressure (5–60 cm H2O). The manovolumetric results were compared with 28 sex and aged matched controls. Rectal evacuation was measured by computer-based image analysis of rectal emptying rate in defaecography. The rectal pressure thresholds for filling, urge and pain did not differ between the groups but there were proportionally more patients in the slow transit and mixed group with thresholds for filling exceeding 25 cm H2O ( P = 0.04). In total, 18% of patients had impaired sensitivity which was associated with long duration of symptoms ( P < 0.05). Patients with grossly impaired rectal sensitivity (filling threshold > 40 cm H2O) had impaired rectal evacuation ( P < 0.05). The rectal compliance was increased in the slow transit and mixed group ( P < 0.01–0.05) in the pressure interval 5–15 cm H2O. Anal resting and squeeze pressures did not differ between the groups although 7/19 in the slow transit group had values around the lower limit of controls. Slow wave frequency was lower in all patient groups ( P < 0.001 vs. controls). Rectal evacuation was not related to sphincter function or to rectal compliance. Clinical categorization of constipated patients defines groups where altered anorectal physiology is not uncommon. Constipation with symptoms of infrequent defaecation may be associated with impaired rectal sensitivity and increased rectal compliance whereas outlet obstruction symptoms are not clearly related to changes in anorectal physiology. [ABSTRACT FROM AUTHOR]

Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of rectal adenomas and also in selected cases of rectal carcinomas. The aim of this study was to assess the results in a consecutive series of patients after introducing the TEM technique. All 58 patients operated with TEM from January 1996 to January 1999 were evaluated in a retrospective review. Forty-eight patients answered a clinically validated questionnaire a median of 22 months after TEM. Eighty patients who had undergone transanal excision and 12 who had undergone York Mason's procedure served as a reference group with respect to recurrence rates. The complication rate was 5% (immediate) and 14% (long-term). The overall 30-day mortality rate was zero. An impairment of continence was seen in 18 (37%) patients. Of these, all 18 experienced varying degree of incontinence to liquid stool, 14 also to flatus and 5 of them even to solid stool. The recurrence rate was 11% in adenomas and 14% in cancers; T1, 1 (10%) recurrence and T2, 1 (50%) recurrence. There was a correlation between operating time and impairment of continence as well as recurrence rate. TEM is a safe procedure, having a low recurrence rate and an acceptable functional outcome. [ABSTRACT FROM AUTHOR]

Objective To compare endoanal ultrasound (EUS) with a 10-MHz probe vs. bodycoil magnetic resonance imaging (MRI) in the preoperative evaluation of anal fistula. Subjects and methods 23 patients with fistula in the anal region underwent preoperative 0.5 T bodycoil MRI and 10 MHz EUS which included probing in 6 patients. The results of the EUS and MRI were compared against the surgical findings as a reference method. Results In classification of the primary tract there was agreement between EUS and surgical findings in 14 (61%) and between MRI and surgery in 11 (48%). Concerning the presence of an internal opening the corresponding figures were 17 (74%) and 10 (43%) and in judging the presence of an extension or an abscess 15 (65%) vs. 11 (48%), respectively. In three out of eight patients with nonhealing or recurrence after surgery preoperative imaging had shown an extension and/or an abscess that was not identified by the surgeon. Conclusion EUS, sometimes complemented with probing, is well comparable to bodycoil MRI in classifying and describing the topography of an anal fistula. [ABSTRACT FROM AUTHOR]

An assessment of the safety of structures may be carried out on the basis of different known safety concepts (global safety factor, semiprobabilistic approach using partial safety factors, probabilistic approximation solution using first- and second-order reliability theory, probabilistic "exact" solution). The application of these concepts presupposes special knowledge concerning input values, e.g., permissible or prescribed values, quantile values, distribution functions. This especially applies to probabilistic methods. Inaccuracies and statistically nondescribable uncertainties in the input data are either ignored in these methods or only accounted for approximately using crisp bounds. Fuzzy set theory enables such uncertainties to be described mathematically and processed in the analysis of structures. The uncertain results of fuzzy structural analysis may be evaluated by various methods. In this article a safety assessment method is described based on possibility theory. In contrast to the above-mentioned concepts, the safety assessment of structures described here takes into account nonstochastic uncertainties and subjective estimates of objective values by experts based on possibility theory. It is possible by this means to obtain sufficiently reliable descriptions of the input data for further processing. The uncertainties introduced into the analysis are later reflected in the results. A realistic description of system behavior is obtained by applying high-quality algorithms in the structural analysis. The uncertain results serve as a starting point for the safety assessment. The method described here forms a supplement to safety concepts already in use. [ABSTRACT FROM AUTHOR]

Thirty patients with seasonal allergic rhinitis entered a double blind study comparing budesonide (nasal spray, 400 μg/d) and i.m. injection of 80 mg methylprednisolone acetate. Symptoms were assessed over a "run in" period of 3-7 days followed by a treatment period of 3 weeks. Pollen counts were evaluated daily. Both the systemic and topical corticosteroid treatment resulted in a significant improvement of nasal and ocular symptoms and were accompanied by reduced antihistamine intake. A comparison of the two treatments in relation to the pollen count yielded statistically significantly fewer nasal symptoms, such as itching, secretion, and sneezing in the budesonide-treated group. Nasal blockage and ocular symptoms remained unchanged, but the use of eyedrops was significantly reduced in the methylprednisolone-treated group. Side effects of both treatments were mild and the incidence negligible. Methylprednisolone-treated patients had a significantly lower cortisol value after 7 days but still had a normal response to ACTH-stimulation. We conclude that the acute symptoms of allergic rhinitis are at least as well ameliorated by regular topical application of budesonide as by a single injection of methylprednisolone acetate. The accompanying allergic conjunctivitis may require additional treatment. [ABSTRACT FROM AUTHOR]

In this article, an approach is introduced which permits the numerical prediction of future structural responses in dependency of uncertain load processes and environmental influences. The approach is based on recurrent neural networks trained by time-dependent measurement results. Thereby, the uncertainty of the measurement results is modeled as fuzzy processes which are considered within the recurrent neural network approach. An efficient solution for network training and prediction is developed utilizing α-cuts and interval arithmetic. The capability of the approach is demonstrated by means of the prediction of the long-term structural behavior of a reinforced concrete plate strengthened by a textile reinforced concrete layer. [ABSTRACT FROM AUTHOR]