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In Australia, despite the growing need for palliative care, there is a shortage of palliative care professionals. The literature suggests that nurse practitioners (NPs) are well positioned to innovate the current model of palliative medicine. This prospective study evaluates the implementation of a new NP role within an established multidisciplinary palliative care service. In this study, patients under the care of the NP had fewer admissions to an acute hospital compared to the rest of the service (17.0% vs. 27.2%), as well as no acute admissions for terminal care and a greater number of patients who achieved their preferred place of death (87.2% vs. 72.2%). A survey of the multidisciplinary team revealed that the majority of responders (93.3%) felt that the NP role had a positive impact on patient care and was holistic, safe, and met patients’ needs. Neutral or negative survey responses highlighted the need for further education or refinement of the role in areas such as prescribing and ability to refer patients directly to medical specialists. Overall, study results were positive and support the introduction of the NP role into a specialist palliative care service but more research is required to assess the effectiveness of the role.

Background A definitive cost analysis of preventing inadvertent perioperative hypothermia (IPH) in surgical patients in Australia is lacking. Preventing IPH is a common nurse-led initiative in surgery and cost savings represent the value of nursing care. Aim The study aims are twofold. First, we aim to estimate the cost of the current prevalence of IPH in Australian hospitals. Second, is to estimate the potential cost reductions that could be realised by reducing IPH prevalence by using a thermal care bundle. Methods Cost-of-illness analysis measures the economic burden of illness to society. It does so by identifying and measuring all costs of a disease or illness such as IPH. It was undertaken using a prevalence approach and a one-year time horizon. Findings The annual costs of IPH to the Australian health system can be estimated to be $1,259,725,856. The annual net benefit of IPH prevention to the Australian health system is $602 million. Using a thermal care bundle to reduce IPH by actively warming 80% of the patients that are not warmed yet could save $657.1 million per year at the expense of $18.4 million. Discussion Preventing IPH using active warming is estimated to lead to significant cost savings across the Australian health system. It is recommended that a national policy for preventing IPH is needed and guidelines must reflect up-to-date strategies for preventing IPH including active prewarming. Conclusion The Thermal Care Bundle should be adopted to lower IPH incidence and associated costs in Australia.

PURPOSE: To classify subtypes of meibomian gland dysfunction (MGD) and evaluate the dependency of dry eye signs, symptoms, and parameters on MGD subtype. DESIGN: Cross-sectional study. Study Population: the right eyes of 447 patients with MGD of various subtypes and 20 healthy volunteers. METHODS: Patients were divided into 4 subtypes of MGD based on meibum expression, meibum quality, and MG loss on meibography images (meibograde of 0-6). Subtypes were patients with high meibum delivery (hypersecretory and nonobvious MGD) and those with low meibum delivery (hyposecretory and obstructive MGD). Additional clinical tests included tear film break-up time (TFBUT), ocular staining, osmolarity, Schirmer I, blink interval timing and the Ocular Surface Disease Index (OSDI) questionnaire. RESULTS: A total of 78 eyes had hypersecretory MGD; 49 eyes had nonobvious MGD; 66 eyes had hyposecretory MGD; and 254 eyes had obstructive MGD. Increased tear film osmolarity and lower TFBUT were found in the low-delivery groups; hyposecretory (P = 0.006, P = 0.016) and obstructive MGD (P = 0.008, P = 0.006) relative to high-delivery MGD (hypersecretory and nonobvious groups, respectively). Worse ocular symptoms and ocular staining were also found in low-delivery MGD groups than the high delivery MGD groups (P amp;lt; 0.01 and P amp;lt; 0.006, respectively). " CONCLUSIONS: Patients with low-delivery MGD had worse dry eye parameters and ocular symptoms than those with high meibum delivery, indicating the pivotal role of meibum secretion in ocular surface health that should be targeted in MGD therapy. Furthermore, nonobvious MGD cannot be diagnosed using conventional dry eye tests and requires morphologic assessment of meibography images to confirm MG loss. ((C) 2019 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The 21-cm notch-to-nipple distance has been accepted without academic scrutiny as a key measure in breast aesthetics. The Fibonacci sequence and phi ratio occur frequently in nature. They have previously been used to assess aesthetics of the face, but not the breast. This study aims to assess if the static 21-cm measure or the proportional phi ratio is associated with ideal breast aesthetics. Method: Subclavicular-breast height and breast width were used to calculate the aesthetic ratio. Subjects were subsequently aesthetically rated. A one-sample t-test was used to determine if the ratio for each breast differed from phi. Breast scores with one, both, or no breasts were compared with an optimal phi ratio. Analysis of variance was performed. Tukey-Kramer adjustment for multiple comparisons was used when pairwise comparisons were conducted. Results: Five subjects (14%) had bilateral optimal phi ratio breasts. Four subjects (11%) had one breast with an optimal phi ratio. Subjects with bilateral optimal phi ratios had significantly higher overall breast scores than those with only one optimal breast (Delta = 0.86, P = 0.025) or no optimal breast (Delta = 0.73, P = 0.008). Distance from optimal Fibonacci nipple position was moderately to strongly correlated with aesthetic score (-0.630, P = 0.016). No correlation was found between 21-cm notch-to-nipple distance and aesthetic score. Conclusion: The bilateral optimal phi ratio is correlated with high overall aesthetic scores, as is the optimal Fibonacci nipple position. No correlation was found between 21-cm notch-to-nipple distance and overall aesthetic score.

Maxillary retrognathia is a well-known consequence of abnormal facial growth in patients with cleft lip and palate. Orthognathic surgery improves facial appearance and occlusion but may induce velopharyngeal insufficiency. The aim of this study was to evaluate the effect of orthognathic surgery on velopharyngeal function by using speech analysis and lateral cephalometric radiographs.We conducted a retrospective study of 47 patients who underwent maxillary advancement ± mandibular setback between 2006 and 2016. Preoperative and 1 year postoperative audio recordings were blinded for scoring by three trained speech therapists. Preoperative and 1 year postoperative lateral cephalometric radiographs were used to obtain information about skeletal movement and its relationship with the velopharyngeal area. Correlations between speech outcomes and cephalometric radiographs were determined.Hyponasality improved significantly after surgery (p 0.05), whereas hypernasality deteriorated significantly only in patients who underwent maxillary advancement alone (p 0.05). No difference in speech parameters was found between patients with hypernasality or patients who had a pharyngoplasty preoperatively and the rest of the group. No correlation was found between the amount of maxillary advancement and hypernasality. A significant correlation (r -0.49, p 0.05) was found between the preoperative velar length and hypernasality postoperatively.Maxillary advancement has a negative impact on velopharyngeal function, whereas bimaxillary surgery seems to protect from deterioration. No difference was found in the amount of maxillary advancement or in velopharyngeal measurements between the Le Fort I group and the bimaxillary group. A short soft palate is a predictor of hypernasality after orthognathic surgery.

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's rho, and Kendall's tau. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P

Background Technology is increasingly transforming the way we interact with others and undertake activities in our daily lives. The healthcare setting has, however, not yet realised the potential of technology solutions to facilitate communication between patients and healthcare providers. While the procedural and policy requirements of healthcare systems will ultimately drive such solutions, understanding the preferences and attitudes of patients is essential to ensure that technology implemented in the healthcare setting facilitates communication in safe, acceptable, and appropriate ways. Therefore, the purpose of this study was to examine patient preferences for using technology to communicate with health service providers about symptoms experienced following discharge from the hospital. Methods Primary data were collected from patients admitted to a large metropolitan hospital in Australia during three consecutive months in 2018. Participants were asked about their daily use of technology including use of computers, email, phone, text messaging, mobile applications, social media, online discussion forums, and videoconference. They were then asked about their use of technologies in managing their health, and preferences for use when communicating about symptoms with health service providers following discharge from hospital. Results Five hundred and twenty-five patients with a wide range of differing clinical conditions and demographics participated. Patients indicated they used a range of technologies in their everyday lives and to manage their health. Almost 60% of patients would prefer to return to hospital if they were experiencing symptoms of concern. However, if patients experienced symptoms that were not of concern, over 60% would prefer to communicate with the hospital via telephone or using technology. Admitting condition, income, and age were significantly associated with preferences for communication about symptoms following hospital discharge. Conclusions Patients have varied preferences for communicating with their health service providers post-hospital discharge. Findings suggest that some, but not all patients, would prefer to use technology to traditional methods of communicating with the healthcare team. Health services should offer patients multiple options for communicating about their recovery to ensure individual needs are appropriately met.

Eksisjon av hudlesjoner gjøres regelmessig i allmennpraksis. Prosedyren er enkel, men riktig utførelse forutsetter kunnskap om hudanatomi og basalkirurgiske prinsipper. Denne artikkelen presenterer indikasjoner for eksisjon av hudlesjoner samt en anbefalt fremgangsmåte basert på klinisk erfaring og relevant litteratur. Fremgangsmåten kan brukes på både pigmenterte og ikke-pigmenterte lesjoner. Seboreiske keratoser omtales ikke (1). Artikkelens innhold er rettet mot primærhelsetjenesten.

Damage to limbal stem cells as a result of injury or disease can lead to limbal stem cell deficiency (LSCD). This disease is characterized by decreased vision that is often painful and may progress to blindness. Clinical features include inflammation, neovascularization, and persistent cornea epithelial defects. Successful strategies for treatment involve transplantation of grafts harvested from the limbus of the alternate healthy eye, called conjunctival‐limbal autograft (CLAU) and transplantation of limbal cell sheets cultured from limbal biopsies, termed cultured limbal epithelial transplantation (CLET). In 2012, Sangwan and colleagues presented simple limbal epithelial transplantation (SLET), a novel transplantation technique that combines the benefits of CLAU and CLET and avoids the challenges associated with both. In SLET a small biopsy from the limbus of the healthy eye is divided and distributed over human amniotic membrane, which is placed on the affected cornea. Outgrowth occurs from each small explant and a complete corneal epithelium is typically formed within 2 weeks. Advantages of SLET include reduced risk of iatrogenic LSCD occurring in the healthy cornea at harvest; direct transfer circumventing the need for cell culture; and the opportunity to perform biopsy harvest and transplantation in one operation. Success so far using SLET is comparable with CLAU and CLET. Of note, 336 of 404 (83%) operations using SLET resulted in restoration of the corneal epithelium, whereas visual acuity improved in 258 of the 373 (69%) reported cases. This review summarizes the results of 31 studies published on SLET since 2012. Progress, advantages, challenges, and suggestions for future studies are presented., This review examines work reporting simple limbal epithelial transplantation (SLET), an innovative technique that uses minimal limbal tissue from the healthy eye to regenerate the cornea in the limbal deficient diseased eye. SLET has the advantages of requiring only 2 mm × 2 mm of limbal tissue; harvest and transplantation is achieved in a single operation; and cell culture laboratories are unnecessary.

All researchers for development struggle to achieve lasting results on the ground. Regardless of the introduced technology, the fundamental basis for achieving lasting results involves: 1) strategic project leadership, 2) local ownership of research objectives, research design, outputs and overall results, and 3) local leadership and management of activities and finances. To support lasting results, research tools can assist in communicating the complexities of an introduced technology and can guide stakeholder interactions to bridge knowledge systems and create common understandings and new hybrid knowledge systems. We highlight a transdisciplinary process used to co-create a Research Discussion Tool and identification of 9 thematic areas which, in combination, enabled obstacles to technology uptake to be overcome and farmers to benefit from research-based innovations. The process involved assisting local researchers and extension agents to co-develop solutions, strategies and methods to improve technology uptake by farmers in Lao PDR, using a series of change management interventions. A complex ecology of factors involving farmers’ decision drivers and farmers’ decision enablers within farmers’ production systems influence technology uptake. The relative importance of each factor is dependent on the specific technology that is being introduced. Hence, projects that introduce new technologies grapple to address all relevant factors and often do not have the ability to deal with the complex array of factors that are at play. Co-constructed knowledge embeds local knowledge that becomes accessible to projects. The approach also has the potential to harness collaborative exchanges with other projects in similar geographical regions.

Background: Autologous fat transplantation has been used to treat mild velopharyngeal insufficiency (VPI) for the last two decades. The effectiveness of this technique has been evaluated by assessing speech and measuring velopharyngeal closure. Few studies have considered the subjective opinion of the patient and their parents. This study aimed to evaluate the quality of life (QOL) of patients who had undergone fat transplantation using a validated questionnaire, VPI Effects on Life Outcome (VELO). Patients and methods: Two copies of the questionnaire VELO were administered to 26 patients with mild VPI who had undergone fat transplantation between 2006 and 2015. All patients were nonsyndromic, and 17 of them had cleft palate. All clefts had been repaired prior to fat transplantation. Both patients and their parents, for those younger than 18 years, completed two questionnaires each: the first one referred to the preoperation QOL, while the second one referred to the current QOL. Results: The total score and “Speech limitations,” “Situational difficulty,” and “Emotional impact” subscores improved significantly (p

Autologous breast reconstruction (BR) aims to restore body image and improve health-related quality of life in women undergoing mastectomy due to breast cancer. We wanted to explore patient-reported cosmetic results and satisfaction 10 or more years post BR surgery, using deep inferior epigastric perforator flap (DIEP). This is a follow-up study based on the same patient population of 34 patients undergoing delayed DIEP-flap procedure during 2001-2004 at Oslo University Hospital investigated by our group and published in 2008; Four patients died during the 10 years' follow-up time and four patients with total or partial flap failure were excluded. The average age for reconstruction was 51.4 years (SD 5.8). The participants answered study-specific questions based on the first study, evaluated cosmetic results using the visual analog scale (VAS) and BREAST-Q post-mastectomy reconstruction module. The response rate was 85% (22/26). A significantly reduced number of patients reported satisfaction with the appearance of breasts (p = .035). The consistency of the reconstructed breast was significantly better evaluated with VAS score (p = .039). The patients reported overall satisfactory results based on Q-scores using the BREAST-Q post-mastectomy reconstruction module. Patients reported a generally high level of satisfaction with BR and cosmetic results 10 or more years after delayed DIEP-flap procedure. Although a significantly decreased number of patients reported satisfaction with the appearance of the breast, almost all patients would have chosen BR again, and the consistency of the reconstructed breast was evaluated as improved.

Despite many advances in vehicle safety technology, traffic fatalities remain a devastating burden on society. With over two-thirds of all fatal single-vehicle crashes occurring off the roadway, run-off-road (ROR) crashes have become the focus of much roadway safety research. Current countermeasures, including roadway infrastructure modifications and some on-board vehicle safety systems, remain limited in their approach as they do not directly address the critical factor of driver behaviour. It has been shown that ROR crashes are often the result of poor driver performance leading up to the crash. In this study, the performance of two control algorithms, sliding control and linear quadratic control, was investigated for use in an autonomous ROR vehicle recovery system. The two controllers were simulated amongst a variety of ROR conditions where typical driver performance was inadequate to safely operate the vehicle. The sliding controller recovered the fastest within the nominal conditions but exh...

The automotive steering system is the primary channel through which road and vehicle behavior feedback is transmitted to the driver. While the driver provides directional platform control through the steering wheel, perceptions of the vehicle’s handling responsiveness are simultaneously transmitted back to the driver allowing for correction of any instabilities the vehicle may encounter. Based on these factors, drivers often pay special attention to the steering system when deciding what vehicle to purchase. Therefore, a significant amount of effort and time is invested in attempting to determine the optimal design of steering system components and configurations. In this study, the determination of an optimal steering configuration was attempted based on responses obtained from questionnaires that subjects answered. The questions were designed to evaluate the degree of satisfaction regarding the “control”, “ease of operation”, and “fun” participants experienced after each driving run. During the study, human subjects drove a driving simulator for 15 combinations of 3 different roadway environments and 5 different steering configurations, filling out a questionnaire after each scenario. The subjects were also classified as a type of driver (“utility”, “enthusiast”, and/or “performance”). The study attempted to determine if the mean values of questionnaire responses for “control”, “ease”, and “fun” type of questions changed as the scenario and/or driver type changed. Analysis of Variance (ANOVA) was used to determine if the mean values of the three types of questions were statistically different. The overall results suggest that the average responses for vehicle “control”, “ease”, and the “fun” type of questions were dependent on the type of roadway environment; however, only the responses for “fun” type of questions were influenced by the given steering configurations. Indeed, the steering system can impact the driver’s perceptions of the vehicle’s operational experience.

The hasukjip (하숙집) is a form of small business in Korea. It consists of a house with several (sometimes up to a dozen or more) boarding rooms. Many Korean and foreign students living in hasukjips and Koreans understand hasukjips only as a type of private dormitory, but if we examine the example of changes in hasukjips we can also consider trends in Korean society. Although hasukjips reflect elements and aspects of various sides of life in Korea, Korean and foreign scholars have not undertaken research on the history of the hasukjip or changes in its history and this institution remains practically unknown in the Western academic world. The aim of this article is to consider elements of the history of the hasukjip and its place in Korean life.

Aim: To find out if subjects with 22q11.2 deletion syndrome (DS) have a different velopharyngeal anatomy which could cause velopharyngeal insufficiency (VPI). Methods: A prospective study of 16 subjects >16 years of age with 22q11.2 DS, without overt cleft palate and without previous VPI surgery, and 48 healthy controls >18 years of age were included in the study. Speech was recorded and scored blindly by two independent senior speech therapists. All 64 individuals had MRI scans, which were analyzed blindly by a consultant radiologist. Results: Subjects with 22q11.2 DS had a mild degree of weak pressure consonants (mean score); borderline to mild degree of hypernasality and audible nasal emission (mean score). All controls had normal speech. When comparing subjects (22q11.2 DS) to controls, we found the subjects to have the following: A shorter distance between left and right points of origin of the levator veli palatini muscle (LVP) (p

We report the case of a newborn boy with multinodular NRAS and BRAF mutation-negative congenital melanocytic nevi and cerebral lesions compatible with congenital intraparenchymal melanosis. Histopathology from skin lesions showed atypical nodular melanocytic proliferation with marked melanocytic atypia and a large number of mitoses and apoptosis, indicating aggressive proliferation. The child developed several new subcutaneous tumors and multiple internal lesions, which were confirmed to be metastases, and died at 5 months of age. This case may represent an infantile melanoma developing from a giant congenital melanocytic nevus or a congenital melanoma.

A run-off-road (ROR) event occurs when one or more of a vehicle's wheels leaves the roadway and begins to travel on the surface or shoulder adjacent to the road. Despite various countermeasures, ROR crashes continue to yield a large number of fatalities and injuries. Infrastructure-based solutions do not directly address the critical factor of driver performance preceding and during an ROR event. In this study, a total of 75 individuals participated in a pre-post experiment to examine the effect of a training video on improving driver performance during a set of simulated ROR scenarios (e.g., on a high speed highway, a horizontal curve, and a residential rural road). In each scenario, the vehicle was unexpectedly forced into an ROR scenario for which the drivers were instructed to recover as safely as possible. The treatment group then watched a custom ROR training video while the control group viewed a placebo video. The participants then drove the same simulated ROR scenarios. The results suggest that the training video had a significant positive effect on drivers' steering response on all three roadway conditions as well as improvements in vehicle stability, subjectively rated demand on the driver, and self-evaluated performance in the highway scenario. Under the highway conditions, the treatment group reduced the frequency of spinouts from 70% in the pre-training events to 16% in the post-training events (χ(2)(1)=23.32, p

Managed Aquifer Recharge (MAR) of stormwater has been deemed technically feasible in augmenting the total water supplies of the Adelaide region however, a major obstacle to implementation of new water schemes, particularly for potable reuse, can be gaining public acceptance and political support. The present survey of 1043 Adelaide residents addressed factors identified in the literature such as satisfaction with the quality of water, the importance of cost, perceived effectiveness of the recycled water distribution system, perceptions of community acceptance and trust in the water authorities to manage the system. The study compares three options for the use of stormwater through MAR: non-potable use through a third-pipe system, potable use whereby the water from the aquifer is pumped to a reservoir, and potable use whereby locally treated water from the aquifer is pumped into the mains system. Although respondents were positive about the reuse of stormwater via MAR for both potable and non-potable options and the likelihood of protest was less than ten percent, respondents clearly preferred the non-potable to the potable options. The results suggested a need for public education on issues such as the cost of third-pipe systems, the risks associated with the potable option with localised treatment, and the actual rate of community acceptance, which was higher than they believed. However, there was also evidence of psychological bias, which is not easily moved by the provision of information alone.

For the last two decades, autologous fat transplantation has been used to treat mild velopharyngeal insufficiency (VPI); however, there is still disagreement about its effectiveness. The aim of the study was to evaluate the procedure by using speech analysis and magnetic resonance imaging (MRI).This is a prospective study of 47 non-syndromic patients with mild VPI who underwent autologous fat transplantation to the velopharynx between 2006 and 2015. Thirty-two patients had a cleft palate, all of which had been repaired before fat transplantation. Eight patients developed VPI after adenotonsillectomy, one after uvulo-palatoplasty and six had VPI of unknown etiology. Twelve patients underwent two procedures of fat transplantation. Preoperative and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists on a five-point scale. Preoperative and 1-year postoperative MRIs were obtained during phonation, measuring the velopharyngeal distance and the velopharyngeal gap area. Correlations between the speech outcomes and MRI were calculated.Audible nasal emission was the only speech parameter that improved significantly postoperatively (p = 0.005). A significant reduction in both velopharyngeal distance (p 0.005) and the gap area (p 0.005) was found after treatment. A significant improvement in the mobility of the velum was observed after treatment (p = 0.03). There was no significant correlation between speech outcomes and MRI.Autologous fat transplantation for the treatment of mild VPI, although significantly reducing audible nasal emission, made no significant improvement in hypernasality or nasal turbulence. No complications were observed.

Transplantation of cultured epidermal cell sheets (CES) has long been used to treat patients with burns, chronic wounds, and stable vitiligo. In patients with large area burns this can be a life-saving procedure. The ultimate goal, however, is to restore all normal functions of the skin and prevent scar formation. Increased focus on the incorporation of epidermal stem cells (EpiSCs) within CES transplants may ultimately prove to be key to achieving this. Transplanted EpiSCs contribute to restoring the complete epidermis and provide long-term renewal. Maintenance of the regenerative potential of EpiSCs is anchorage-dependent. The extracellular matrix (ECM) provides physical cues that are interpreted by EpiSCs and reciprocal signaling between cells and ECM are integrated to determine cell fate. Thus, the carrier scaffold chosen for culture and transplant influences maintenance of EpiSC phenotype and may enhance or detract from regenerative healing following transfer. Long-term effectiveness and safety of genetically modified EpiSCs to correct the severe skin blistering disease epidermolysis bullosa has been shown clinically. Furthermore, skin is gaining interest as an easily accessible source of adult epithelial stem cells potentially useful for restoration of other types of epithelia. This review highlights the role of EpiSCs in the current treatment of skin injury and disease, as well as their potential in novel regenerative medicine applications involving other epithelia.

Background Women, on average, have less muscle strength than men. This anthropometric-physiological trait may make them more vulnerable to ex - cessive physical strain, injury, and inability to work. Strength training is used for preventive health maintenance and to lessen musculoskeletal symptoms. In this context, we studied whether the degree of muscle strength has any effect on women's health in everyday working life, and also the effects of strength training for women on their health in the workplace. Methods We systematically searched the PubMed/MEDLINE, Embase, CINAHL, Web of Science, CENTRAL, and SPOLIT databases for pertinent publications, in accordance with the PRISMA criteria for literature searches. We analyzed all of the retrieved randomized controlled trials conducted on women aged 18 to 65 to determine the effects of training on muscle strength, physical performance ability, and health-related parameters including body composition, musculo - skeletal pain, and subjective well-being. Results We did not find any studies that provided answers to the first question. As for the second question, the selection criteria were met by 12 of the 4969 retrieved studies, which dealt with the effect of strength training on health in the occupational environment and involved a total of 1365 female subjects. These studies were carried out in heterogeneous subject groups, with a variety of overlapping interventions consisting of both strength and endurance training. Significantly increased strength was found in all studies, as was a reduction of pain in all of the studies where this question was asked. Inconsistent results were obtained with respect to body weight, body composition, and subjective well-being. Conclusion The interventions that were conducted in these studies succeeded in increasing strength and reducing pain, even when the training was brief and of low intensity. This was true not only for women working in occupations requiring unusual physical strength, but also for those in sedentary occupations. The small number of studies performed on this subject to date is surprising in view of the high prevalence of musculoskeletal symptoms in women.

Traffic fatalities and injuries continue to demand the attention of researchers and governments across the world as they remain significant factors in public health and safety. Enhanced legislature, together with vehicle and roadway technology, has helped to reduce the impact of traffic crashes in many scenarios. However, one specifically troublesome area of traffic safety which persists is the run-off-road crash where a vehicle’s wheels leave the paved portion of the roadway and begin to travel on the shoulder or side of the road. Large percentages of fatal and injury traffic crashes are attributed to run-off-road events. One of the most critical reasons why run-off-road scenarios quickly evolve into serious crashes is poor driver performance. Drivers are unprepared to handle the situation safely and often execute dangerous maneuvers, such as overcorrection, which can lead to devastating results. One countermeasure which directly addresses the driver performance is driver education and training. In this article, a simulator-based driving environment is proposed specifically for run-off-road recovery training. A human subject study is used to validate the simulator as an effective tool for replicating the run-off-road experience with the additional benefit of receiving insight into driver reactions to run-off-road events. Analysis of variance (ANOVA) results of subjective questionnaire data and objective performance evaluation parameters show strong correlations to run-off-road crash data and previous run-off-road study conclusions. In particular, higher vehicle velocities, curved roads, and larger differences between the friction coefficient of the road and the friction coefficient of the shoulder all negatively impacted drivers’ recoveries from run-off-road scenarios. The only non-significant impact found was that of the roadway edge, indicating a possible limitation of the simulator system with respect to that particular environment variable. The validation study provides a foundation for further evaluation and development of a simulator-based run-off-road recovery training program to help to equip drivers with the skills to recognize and recover safely from this dangerous and often deadly scenario.

There is a growing understanding that the impacts of climate change affect different communities within a country, in a variety of ways—not always uniformly. This article reports on research conducted in the middle hills region of Nepal that explored climate change vulnerability in terms of exposure, sensitivity and adaptive capacity across different well-being groups, genders of the head of household and household location. In the study region, dry land farming has increasingly experienced climate-induced changes to farm productivity and natural resources. The experience of vulnerability to decreased livelihood options and natural resource hazards due to a changing climate varied according to household wealth and well-being status, with very poor and poor households more vulnerable than medium and well-off households. The research indicates that the climate change adaptation would benefit by considering: (i) differential impacts of vulnerability mainly based on well-being status of households; (ii) understanding of the local socio-political context and underlying causes of vulnerability and its application; and (iii) identifying vulnerable populations for the units of vulnerability analysis and adaptation planning.

IntroductionPatient-reported outcome measures (PROMs) are data capture tools that collect information directly from patients. Several large research studies provide evidence that the use of PROMs in routine care provides benefits to mortality and morbidity outcomes in medical oncology patients. Despite this, implementation of PROMs in daily clinical routine is slow and challenging.Methods and analysisThis study will use a stepped-wedge design to assess the implementation of a PROM intervention in highly frequented medical oncology outpatient clinics. During a lead-in period of 4 weeks, control data will be collected. The intervention will then be implemented for 4 weeks in Clinic 1 initially, then in Clinic 2 for another 4 weeks. 500 patient encounters will be measured over the 12 weeks in total. The process of implementation will be informed and evaluated using the Medical Research Council Guidelines for Implementing Complex Interventions. The study will be guided by the Promoting Action Research in Health Services framework approach for implementation. The intervention and implementation outcomes will be measured using qualitative and quantitative data.Ethics and disseminationEthical approval has been obtained, approval number HREC/16/QRBW/100 by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee. Results will be disseminated in peer-reviewed journals and at scientific meetings.Trial registrationACTRN12618000398202. Trial Status: Opened on 25 March 2018 and will continue until 12 months after the last PROMs reporting encounter.

Social networks play an important role in environmental governance regimes, and they are a key to the adaptive capacity of systems that deal with complex, contextual and multi-faceted issues. Urban water systems are typical examples of complex systems facing many pressures, such as increased population, water quality deterioration, and climate change. This paper explores social networks of the key stakeholders engaged in urban water management, in Makassar City, Indonesia, in the context of exploring ways to improve management of an increasingly complex urban water system. Three social networks were explored; those constituted by formal and informal interactions and networks perceived by stakeholders to be “ideal”. Formal networks were identified through an examination of the legislative instruments and government agencies’ documents relating to water provision in Makassar, while the informal and “ideal” networks were investigated in collaboration with the stakeholders. The research found that the informal social network was more extensive than were the formally required networks, and the investigation of informal networks created a potentially more robust and adaptive water management system than would have occurred through inclusion of formal institutional arrangements. We suggest that in examination of the adaptive capacity of an urban water system, one also considers the informal arrangements and linkages, as this additional information about the system is necessary to enhance our understanding of potential adaptation of water management and improved urban water systems.

Background There are no previous blinded studies for comparison of preoperative versus postoperative perceptual speech assessments when using a pharyngeal flap for treating velopharyngeal insufficiency (VPI) in patients diagnosed with 22q11.2 deletion syndrome. The aim of the study was to evaluate the effect of superiorly based pharyngeal flap surgery on speech in these patients using blinded judgments of experienced speech therapists. Methods A retrospective study of 12 consecutive patients who had undergone pharyngeal flap surgery for treatment of VPI between 2002 and 2009 was conducted. Seven girls and 5 boys between 4 and 15 (median, 6) years old at the time of surgery were included in the study. Six patients were born with a submucous cleft palate (including 2 occult), and 1 patient, with an overt cleft palate. The remaining 5 patients had no signs of a palatal pathology. All palatal clefts had been repaired before pharyngeal flap surgery except in 2 patients with occult submucous cleft palate. Preoperative and postoperative audio recordings were blinded for scoring independently by 3 senior speech therapists. Results There was a significant improvement in hypernasality (P = 0.002), audible nasal emission (P = 0.033), weak pressure consonants (P = 0.008), and speech intelligibility (P = 0.021) after pharyngeal flap surgery. Hyponasality did not develop significantly with surgery. One patient was diagnosed with obstructive sleep apnea. Conclusions Superiorly based pharyngeal flap resulted in a significant speech improvement in 12 consecutive patients with 22q11.2 deletion syndrome having VPI.

Lymphatic malformations are rare developmental non-malignant abnormalities that present as masses consisting of abnormal growth of fluid filled channels or spaces in the skin or deep tissue that result in abnormalities of lymphatic flow. They may cause symptoms like pain, recurrent lymphorrea, abnormal bone growth, and disturbance of bodily functions. They may also be a cosmetic problem. The study aims to describe the population with lymphatic malformations (LM) treated at a national referral centre.This is a retrospective review of patients with the diagnosis lymphatic malformation seen at the centre between 2006-2013. The authors performed a systematic review of the hospital records and a reevaluation of the radiological findings. Eighty-five patients with 102 lymphatic malformations were included.The majority of the patients (67%) were diagnosed before the age of 2 years. Lesions were located mainly to the head and neck (64%) and half (52%) were macrocystic. Treatment was: sclerotherapy (69%), surgery (49%), laser therapy (19%), or a combination of these treatment modalities (33%). The best outcome was found in the patients with macrocystic lesions (p = .029), and 76% of the patients reported a good or very good outcome.Most patients presented before the age of 2 years with complex lesions which required unique, often multimodal treatment plans and in general they experienced good outcome.

OBJECTIVES: The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen.MATERIALS AND METHODS: A total of 115 patients (mean age 51±13years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention.RESULTS: There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients.CONCLUSION: De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.

Background: Reconstructive procedures with pedicled and free flaps are associated with a risk of ischemia. Prostaglandin E1 (PGE1) is a hormone-like substance with known antiischemic and tissue-protective effects. The aim of this study was to evaluate the effect of PGE1 on the microcirculation in random pattern skin flaps on rats. Methods: Twenty-four rats were divided into 2 groups: an intervention group given PGE1 for 6 hours and a control group given saline. The flap (2 × 10 cm) was created on the back of the rats, and the microcirculation was monitored with laser Doppler perfusion imaging in 5 different zones (1, proximal; 5, distal) before surgery and after 60, 180, and 360 minutes postoperatively. Results: Before surgery, there was no difference in the perfusion in any zones between the intervention group and the control group. The mean perfusion values in zone 1 in the intervention group were significantly higher than those in the control group at 60, 180, and 360 minutes postoperatively (P = 0.02, P = 0.05, and P = 0.04, respectively). At 360 minutes, we also found significantly higher levels of perfusion in the intervention group in zones 4 and 5 (P = 0.05 and P = 0.03, respectively) compared with the controls. Comparing the perfusion at 360 to 60 minutes in the intervention group, we found a significant increase in microcirculation in all zones, which were not seen in the control group. Conclusion: PGE1 increased perfusion in the dermal random pattern flaps on rats.

The ALT flap can be considered as an alternative when other conservative autologous breast reconstruction techniques are inappropriate. The main advantage with this flap is that it is a well-known flap for most microsurgeons and it has relatively predictable anatomy with a long pedicle and suitable vessel diameter. The procedure can be performed without repositioning the patient during surgery allowing a two-team approach. The donor site morbidity is limited, although it has to be discussed with each patient. The reconstruction technique is primarily limited to patients with small to moderate breast sizes.

Summary Provision of urban water supplies to rapidly growing cities of South East Asia is difficult because of increasing demand for limited water supplies, periodic droughts, and depletion and contamination of surface and groundwater. In such adverse environments, effective policy and planning processes are required to secure adequate water supplies. Developing a Water Needs Index reveals key elements of the complex urban water supply by means of a participatory approach for rapid and interdisciplinary assessment. The index uses deliberative interactions with stakeholders to create opportunities for mutual understanding, confirmation of constructs and capacity building of all involved. In Can Tho City, located at the heart of the Mekong delta in Vietnam, a Water Needs Index has been developed with local stakeholders. The functional attributes of the Water Needs Index at this urban scale have been critically appraised. Systemic water issues, supply problems, health issues and inadequate, poorly functioning infrastructure requiring attention from local authorities have been identified. Entrenched social and economic inequities in access to water and sanitation, as well as polluting environmental management practices has caused widespread problems for urban populations. The framework provides a common language based on systems thinking, increased cross-sectoral communication, as well as increased recognition of problem issues; this ought to lead to improved urban water management. Importantly, the case study shows that the approach can help to overcome biases of local planners based on their limited experience (information black spots), to allow them to address problems experienced in all areas of the city.

Managed retreat is one of the few policy options available to the Australian government to mitigate the risk of sea level rise for coastal communities. A structured withdrawal from areas inundated by rising sea levels may be the only viable option for some jurisdictions and in many cases may be the most cost effective defensive approach. At present, little is known about community opinions on managed retreat options. The authors present a social functionalist framework to analyse the range of personal concerns and understand more about how people may respond to predicted changes to coastal shorelines. The meta-theoretical social functionalist framework suggests people can intuitively act as scientists, economists, prosecutors, theologians and at times as politicians, when subject to situations that require judgment and choice. Qualitative responses to an online survey were used to categorise participants according to their social functionalist decision-making styles. The study compared the decision-making style of three groups of participants: those concerned, unsure and unconcerned (sceptical/rejectionist) about sea level rise risks. The research demonstrated that the majority of participants used more than one social functionalist framework to intuitively assess managed retreat policies. While all risk profile groups tended to express intuitive scientist concerns, the emotive expressions of intuitive theologians and prosecutors were evident and could undermine policy processes and adaptation initiatives. These findings reinforce the need for further public debate on how to respond to sea level rise. They emphasise that different individuals frame the purpose of those debates in distinct ways; to reach the most effective, equitable and socially legitimate or morally appropriate response, which depends upon what is inherently important to each individual. A major advantage of employing a social functionalist framework analysis is the flexibility to identify the range of positions (more than one worldview) that can be held by members in a community and to be cognisant of the importance of firmly entrenched beliefs, and hence the barriers to constructive dialogue.

Vehicle safety remains a prominent automotive issue for engineers, consumers, and government regulators. One area that merits attention is the safety issue of when a child is left alone in a parked vehicle during the summer months when the ambient air temperatures are warmer. Injuries and deaths of infants, young children, and elderly adults have occurred due to elevated body temperatures for prolonged time periods. One proposed solution is the design of a car safety seat that offers temporary thermal protection to the occupant. This seat features thermoelectric cooling and forced air convection to maintain the body temperature within acceptable ranges for a limited time. In this paper, a system thermal model and experimental results are presented to validate the effectiveness of the thermoelectric-based safety system. The experimental system demonstrates the capability of maintaining localized cabin air temperatures below critical survivability thresholds in a closed parked vehicle for up to 95 minutes. This represents an 85% increase over standard child seating units, in cabin temperatures up to 69°C, for an emulated 7 kg infant.

BACKGROUND Contact with jellyfish can cause skin irritation and manifestations. We wanted to investigate the prophylactic effect of a sun cream containing an inhibitor against jellyfish stings. MATERIAL AND METHOD We recruited 38 persons who were randomised such that each received two of three possible treatments, one on each underarm. Prophylactic treatment with sun cream containing jellyfish sting inhibitor, ordinary sun cream, and no cream. Their underarms were exposed to wet jellyfish tentacles in a watchglass. The following were recorded: time before pain, skin changes after four minutes, and pain intensity after 10 minutes, registered on a VAS scale. RESULTS Thirteen of 25 subjects who had the sun cream with jellyfish sting inhibitor did not register any pain after 4 minutes' exposure, compared with two of 25 and two of 26 who had received pre-treatment with ordinary sun cream (p e 0.32) and no pre-treatment (p < 0.001), respectively. On average, subjects who had received prophylactic treatment with sun cream containing jellyfish sting inhibitor recorded a lower VAS score for pain/discomfort after 10 minutes. The difference was 10.6 mm (95 % CI 3.1-17.9) compared with ordinary sun cream and 14.2 mm (95 % CI 6.9-21.5) compared with no pre-treatment. A smaller number of subjects were found to have underarms with inflamed skin when prophylactic cream containing jellyfish sting inhibitor was used (6 of 25) than when ordinary sun cream was used (11 of 25) or no pre-treatment (12 of 26). There were no statistically significant differences between ordinary sun cream and no pre-treatment for any of the three outcomes. INTERPRETATION Prophylactic treatment with jellyfish sting inhibitor reduces the risk of subjects developing symptoms after exposure to jellyfish tentacles.

Decentralised water systems are considered to be effective, beneficial and are useful in a number of urban and peri-urban settings, and have been implemented to varying degrees across much of Australia. The use of decentralised water systems has introduced a change in the style of water service delivery and often there are new actors responsible and involved in the maintenance and operation of these systems. This raises questions about how to best implement and govern the use of decentralised water systems. To understand the issues and problem mitigation approaches required for decentralised systems, collection of data on the effectiveness, difficulties, functional aspects and ongoing problems in providing water services is required. Understanding the issues involved is not necessarily straightforward, as performance can be viewed from many different perspectives and may be difficult to measure. One key perspective to consider is that of householders, in their role as end-users of decentralised water systems. This paper suggests that dedicated household surveys can provide important information on the performance of decentralised water systems based on personal understanding and experience of these systems. This is stated on the basis of householder survey trials which indeed seem to provide useful information, both in terms of feedback from the individual and in generating a coherent data set from which to statistically model the adequacy of various implementation styles and governance structures. An exploration of data sets from survey trials have contributed to collective learning, necessary in firmly establishing decentralised systems as viable options for the provision of urban water services now and into the future.

Objective To train medical residents and nurses to work together as a patient-centered care (PCC) team on a medical ward and test its feasibility, nurses’ learning, and patient outcomes. Method Working with administrative leadership, we consolidated residents’ patients on one 32-bed ward. Already training residents in an evidence-based patient-centered method, we now trained 5 nurse leaders similarly, and they then trained all staff nurses. A national consultant visited twice. Specific team-building activities for nurses and residents fostered ward interactions. We used a retrospective pre/post/6-month post-design to evaluate nurses’ knowledge and self-efficacy of patient-centered skills. Patients were assigned non-randomly to our unit or comparison units from our emergency room; using a post-test only design, the primary endpoint was patient satisfaction. Results 28 trained nurses showed improvement in knowledge ( p = 0.02) and self-efficacy ( p = 0.001). 81 treatment patients showed no improvement in satisfaction ( p = 0.44). Conclusion Training nurses in patient-centered practices were effective. Unique in this country, we also trained nurses and residents together as a PCC team on a medical ward and showed it was feasible and well accepted. Practice implications We provide a template for team training and urge that others explore this important new area and contribute to its further development.

We have made a quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator (DIEAP) flap on 10 consecutive women having breast reconstruction with a unilateral DIEAP. Laser Doppler perfusion imaging was used for operative scans. Data were recorded 10 minutes after successful microanastomosis. The mean (SD) perfusion for each perfusion zone was calculated. Zone I = 44.2 (6.2); zone II = 35.1 (10.3); zone III = 39.9 (9.2); and zone IV = 21.9 (10.0). There were significant differences between zones I, II, and III and zone IV (p0.001), and zones I and II (p = 0.02). However, there was no significance between zones I and III (p = 0.9), and zones II and III (p = 0.6). The perfusion of zone IV was significantly lower than those in all other zones, which is in keeping with clinical practice in which zone IV is normally discarded to avoid partial necrosis of the flap in unilateral breast reconstruction. Higher values are expected in zone I than zone III, and in zone II than zone III. However, we could not confirm this. We conclude that there are no differences in skin perfusion between zones I and III, and zones II and III. However, the perfusion of zone IV was significantly less than that in all other zones immediately after revascularisation of the DIEAP flap.

Decentralised water supply systems are becoming increasingly affordable and commonplace in Australia and have the potential to alleviate urban water shortages and reduce pollution into natural receiving marine and freshwater streams. Learning processes are necessary to support the efficient implementation of decentralised systems. These processes reveal the complex socio-technical and institutional factors to be considered when developing an enabling environment supporting decentralised water and wastewater servicing solutions. Critical to the technological transition towards established decentralised systems is the ability to create strategic and adaptive capacity to promote learning and dialogue. Learning processes require institutional mechanisms to ensure the lessons are incorporated into the formulation of policy and regulation, through constructive involvement of key government institutions. Engagement of stakeholders is essential to the enabling environment. Collaborative learning environments using systems analysis with communities (social learning) and adaptive management techniques are useful in refining and applying scientists' and managers' knowledge (knowledge management).

Summary Background. Pressure ulcers (decubitus) occur very frequently and are found in 10–20 % of patients in health institutions. Health personnel should be well acquainted with the prophylaxis, assessment and treatment of pressure ulcers. Material and method. The article is based both on a non-systematic search in Medline and Embase using relevant search words, and on our own clinical experience.

Background:. The dermolipectomy of the deep inferior epigastric artery perforator (DIEAP) flap procedure is designed to give an end result as seen with abdominoplasty (AP). Several steps of an AP are, however, not routinely performed. This study compared the patient-reported outcomes between these 2 procedures with an emphasis on the abdomen. Methods:. Thirty-four patients reconstructed with a DIEAP flap (DIEAP group), and 30 patients with an AP (AP group) were asked to complete 2 study-specific questionnaires. The first questionnaire covered abdominal outcomes, whereas the second was concerned with general outcomes. Results:. The DIEAP group was significantly older compared with the AP group. Eighty-five percentage of the DIEAP group and 66 % of the AP group answered the questionnaires. Postoperatively, the DIEAP group was significantly more satisfied with their bodies when dressed (P = 0.009), and there was a trend of DIEAP patients being more satisfied with the appearance of the abdomen (P = 0.085). No significant difference was found comparing outcomes concerning umbilicus, muscle function, pain, scarring, and contour. The DIEAP group was more worried about their health than the AP group postoperatively (P = 0.044). AP patients had a significantly more altered body image (P = 0.016) and increased sexual desire (P = 0.003) than DIEAP patients. There was no significant difference regarding changes in self-image, social relationships, being naked with partner, and overall satisfaction. Conclusion:. DIEAP flap patients were equally as satisfied with the abdomen as AP patients.

Summary Water issues are inherently local and inter-dependent and almost fully reliant on the interaction between humans and their socio-technical environments. Hence, the development of water management policies requires evidence-based information that deals with complex, contextual and multi-faceted issues. Composite indicator methodologies have been found to be useful tools supporting policy development and decision making in several fields. Targeted water management decisions can benefit from indicator methodologies that combine statistical and qualitative information to assess water issues and rank the differing ‘needs’ of locations. However, due to limitations, we argue that indicator methodologies are best supported by a broader deliberative process of engagement, involving in-depth exploration of issues using inclusive and collective learning processes. In this paper, an integrative and deliberative process is described and applied to understand and evaluate watershed resources and management in the Tigum-Aganan watershed, Philippines. Collectively, local knowledge from stakeholders and quantitative information have been used in developing the water needs index, providing data and informing the selection of data sources for use in the index methodology. In subscribing to the exchange of descriptive narratives we achieve a greater degree of context dependence, transparency and stakeholder participation in the assessment process. Whilst our assessment of the usefulness of the composite methodology is subjective, we believe that the methodology shows great promise; in particular in supporting the emergence of collective action.

The aim of this study was to examine pressure sensitivity at the donor site after breast reconstruction with deep inferior epigastric artery perforator (DIEAP). In a cross-sectional survey, 2 groups of patients were analyzed. The DIEAP group consisted of 30 women who had previously had secondary breast reconstruction with DIEAP flap after mastectomy for breast cancer. The control group consisted of 7 women with no previous abdominal incisions planned for secondary breast reconstruction with DIEAP. Pressure thresholds were tested within the margins of the abdominal wall using Semmes-Weinstein monofilaments. In the DIEAP group a pattern of higher pressure thresholds was observed in the proximity of the scar. Comparing the 2 groups, significant higher pressure thresholds were found in the DIEAP group in the scar on both sides and in the midline from the scar to the umbilical level. Our data show that the abdominoplasty performed during breast reconstruction with DIEAP reduces cutaneous sensitivity in the donor site area.

In a cross-sectional postal survey, we compared patient-reported outcomes in patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap or an expandable breast implant (EBI). We included 34 consecutive patients who had breast reconstruction with DIEP flap and 30 patients with EBI. Outcomes were assessed using the Short Form 36 (SF-36) quality of life questionnaire, two study-specific patient satisfaction questionnaires and a visual analogue scale (VAS) on cosmetic result. There were no significant differences in SF-36 subscale scores between the two groups. On the study-specific questionnaire, more patients in the DIEP group were satisfied with the appearance of their breast (P

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients' satisfaction was high after the procedure.