Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

BACKGROUND Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience. CASE PRESENTATION Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings. CONCLUSIONS Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

Quantitative and qualitative research approaches to assess student well-being

Although there is dissimiliarity in theoretical research approaches to subjective well-being and to assessments of well-being, there is agreement regarding the value of well-being, especially among student populations. In the highly structured, achievement-oriented, non-optimal context of a classroom, individual well-being is a necessary pre-condition for learning. Among student populations well-being should not be construed as an achievement enhancer; but, rather, recognized and measured as an educational value of its own. However, it is necessary for the positive bias towards learning at least in highly structured, achievement-orientated, non-optional learning contexts like school [cf. Hascher, T. (2004). Wohlbefinden in der Schule. Münster: Waxmann]. How can it be measured? Since different research approaches lead to a variety of instruments, the following paper will focus on two ways of assessing well-being in school: a questionnaire on student well-being (N = 2014) 1 and a semi-structured daily diary about relevant emotional situations in school (N = 58, period 3 × 2 weeks). Both methods are introduced and their methodological quality is discussed in terms of reliability, validity and in terms of their usefulness for improving school practice. Furthermore, the research potential of combining quantitative and qualitative data on students’ well-being is addressed.

Subjective well-being and exercise in the second halt of life: a critical review of theoretical approaches

Research has shown repeatedly that the “feeling better” effect of exercise is far more moderate than generally claimed. Examinations of subgroups in secondary analyses also indicate that numerous further variables influence this relationship. One reason for inconsistencies in this research field is the lack of adequate theoretical analyses. Well-being output variables frequently possess no construct definition, and little attention is paid to moderating and mediating variables. This article integrates the main models in an overview and analyzes how secondary analyses define well-being and which areas of the construct they focus on. It then applies a moderator and/or mediator framework to examine which person and environmental variables can be found in the existing explanatory approaches in sport science and how they specify the influence of these moderating and mediating variables. Results show that the broad understanding of well-being in many secondary analyses makes findings difficult to interpret. Moreover, physiological explanatory approaches focus more on affective changes in well-being, whereas psychological approaches also include cognitive changes. The approaches focus mostly on either physical or psychological person variables and rarely combine the two, as in, for example, the dual-mode model. Whereas environmental variables specifying the treatment more closely (e.g., its intensity) are comparatively frequent, only the social support model formulates variables such as the framework in which exercise is presented. The majority of explanatory approaches use simple moderator and/or mediator models such as the basic mediated (e.g., distraction hypothesis) or multiple mediated (e.g., monoamine hypotheses) model. The discussion draws conclusions for future research.

Experimental validation of a mean field model of mineralized collagen fiber arrays at two levels of hierarchy

In the course of this study, stiffness of a fibril array of mineralized collagen fibrils modeled with a mean field method was validated experimentally at site-matched two levels of tissue hierarchy using mineralized turkey leg tendons (MTLT). The applied modeling approaches allowed to model the properties of this unidirectional tissue from nanoscale (mineralized collagen fibrils) to macroscale (mineralized tendon). At the microlevel, the indentation moduli obtained with a mean field homogenization scheme were compared to the experimental ones obtained with microindentation. At the macrolevel, the macroscopic stiffness predicted with micro finite element (μFE) models was compared to the experimental stiffness measured with uniaxial tensile tests. Elastic properties of the elements in μFE models were injected from the mean field model or two-directional microindentations. Quantitatively, the indentation moduli can be properly predicted with the mean-field models. Local stiffness trends within specific tissue morphologies are very weak, suggesting additional factors responsible for the stiffness variations. At macrolevel, the μFE models underestimate the macroscopic stiffness, as compared to tensile tests, but the correlations are strong.

State of the art of integrated therapy approaches in the treatment of schizophrenia: empirical evidence and clinical relevance

Objective: Integrated behavior therapy approaches are defined by the combination of behavioral and or cognitive interventions targeting neurocognition combined with other goal-oriented treatment targets such as social cognition, social skills, or educational issues. The Integrated Psychological Therapy Program (IPT) represents one of the very first behavior therapy approaches combining interventions of neurocognition, social cognition, and social competence. This comprehensive group-based bottom-up and top-down approach consists of five subprograms, each with incremental steps. IPT has been successfully implemented in several countries in Europe, America, Australia and in Asia. IPT worked as a model for some other approaches designed in the USA. IPT was undergone two further developments: based on the social competence part of IPT, the three specific therapy programs focusing residential, occupational or recreational topics were developed. Recently, the cognitive part of INT was rigorously expanded into the Integrated Neurocognitive Therapy (INT) designed exclusively for outpatient treatment: INT includes interventions targeting all neurocognitive and social cognitive domains defined by the NIMH-MATRICS initiative. These group and partially PC-based exercises are structured into four therapy modules, each starting with exercises on neurocognitive domains followed by social cognitive targets. Efficacy: The evidence of integrated therapy approaches and its advantage compared to of one-track interventions was becoming a discussion tool in therapy research as well as in mental health systems. Results of meta-analyses support superiority of integrated approaches compared to one-track interventions in more distal outcome areas such as social functioning. These results are in line with the large body of 37 independent IPT studies in 12 countries. Moreover, IPT research indicates the maintenance of therapy effects after the end of therapy and some evidence generalization effects. Additionally, the international randomized multi-center study on INT with 169 outpatients strongly supports the successful therapy of integrated therapy in proximal and distal outcome such as significant effects in cognition, functioning and negative symptoms. Clinical implication: therapy research as well as expert’s clinical experience recommends integrated therapy approaches such as IPT to be successful agents within multimodal psychiatric treatment concepts. Finally, integrated group therapy based on cognitive remediation seems to motivate and stimulate schizophrenia inpatients and outpatients to more successful and independent life also demanded by the recovery movement.

No shift to a deeper water uptake depth in response to summer drought of two lowland and sub-alpine C3-grasslands in Switzerland

Temperate C3-grasslands are of high agricultural and ecological importance in Central Europe. Plant growth and consequently grassland yields depend strongly on water supply during the growing season, which is projected to change in the future. We therefore investigated the effect of summer drought on the water uptake of an intensively managed lowland and an extensively managed sub-alpine grassland in Switzerland. Summer drought was simulated by using transparent shelters. Standing above- and belowground biomass was sampled during three growing seasons. Soil and plant xylem waters were analyzed for oxygen (and hydrogen) stable isotope ratios, and the depths of plant water uptake were estimated by two different approaches: (1) linear interpolation method and (2) Bayesian calibrated mixing model. Relative to the control, aboveground biomass was reduced under drought conditions. In contrast to our expectations, lowland grassland plants subjected to summer drought were more likely (43–68 %) to rely on water in the topsoil (0–10 cm), whereas control plants relied less on the topsoil (4–37 %) and shifted to deeper soil layers (20–35 cm) during the drought period (29–48 %). Sub-alpine grassland plants did not differ significantly in uptake depth between drought and control plots during the drought period. Both approaches yielded similar results and showed that the drought treatment in the two grasslands did not induce a shift to deeper uptake depths, but rather continued or shifted water uptake to even more shallower soil depths. These findings illustrate the importance of shallow soil depths for plant performance under drought conditions.

Asthma and obesity in children: current evidence and potential systems biology approaches.

Both obesity and asthma are highly prevalent, complex diseases modified by multiple factors. Genetic, developmental, lung mechanical, immunological and behavioural factors have all been suggested as playing a causal role between the two entities; however, their complex mechanistic interactions are still poorly understood and evidence of causality in children remains scant. Equally lacking is evidence of effective treatment strategies, despite the fact that imbalances at vulnerable phases in childhood can impact long-term health. This review is targeted at both clinicians frequently faced with the dilemma of how to investigate and treat the obese asthmatic child and researchers interested in the topic. Highlighting the breadth of the spectrum of factors involved, this review collates evidence regarding the investigation and treatment of asthma in obese children, particularly in comparison with current approaches in 'difficult-to-treat' childhood asthma. Finally, the authors propose hypotheses for future research from a systems-based perspective.

Taking personalized medicine seriously: Biomarker approaches in phase IIb/III studies in major depression and schizophrenia

The success rate in the development of psychopharmacological compounds is insufficient. Two main reasons for failure have been frequently identified: 1) treating the wrong patients and 2) using the wrong dose. This is potentially based on the known heterogeneity among patients, both on a syndromal and a biological level. A focus on personalized medicine through better characterization with biomarkers has been successful in other therapeutic areas. Nevertheless, obstacles toward this goal that exist are 1) the perception of a lack of validation, 2) the perception of an expensive and complicated enterprise, and 3) the perception of regulatory hurdles. The authors tackle these concerns and focus on the utilization of biomarkers as predictive markers for treatment outcome. The authors primarily cover examples from the areas of major depression and schizophrenia. Methodologies covered include salivary and plasma collection of neuroendocrine, metabolic, and inflammatory markers, which identified subgroups of patients in the Netherlands Study of Depression and Anxiety. A battery of vegetative markers, including sleep-electroencephalography parameters, heart rate variability, and bedside functional tests, can be utilized to characterize the activity of a functional system that is related to treatment refractoriness in depression (e.g., the renin-angiotensin-aldosterone system). Actigraphy and skin conductance can be utilized to classify patients with schizophrenia and provide objective readouts for vegetative activation as a functional marker of target engagement. Genetic markers, related to folate metabolism, or folate itself, has prognostic value for the treatment response in patients with schizophrenia. Already, several biomarkers are routinely collected in standard clinical trials (e.g., blood pressure and plasma electrolytes), and appear to be differentiating factors for treatment outcome. Given the availability of a wide variety of markers, the further development and integration of such markers into clinical research is both required and feasible in order to meet the benefit of personalized medicine. This article is based on proceedings from the "Taking Personalized Medicine Seriously-Biomarker Approaches in Phase IIb/III Studies in Major Depression and Schizophrenia" session, which was held during the 10th Annual Scientific Meeting of the International Society for Clinical Trials Meeting (ISCTM) in Washington, DC, February 18 to 20, 2014.

Neural change following different memory training approaches in very preterm born children - A pilot study.

OBJECTIVE There is mixed evidence regarding neural change following cognitive training. Brain activation increase, decrease, or a combination of both may occur. We investigated training-induced neural change using two different memory training approaches. METHODS Very preterm born children (aged 7-12 years) were randomly allocated to a memory strategy training, an intensive working memory practice or a waiting control group. Before and immediately after the trainings and the waiting period, brain activation during a visual working memory task was measured using fMRI and cognitive performance was assessed. RESULTS Following both memory trainings, there was a significant decrease of fronto-parietal brain activation and a significant increase of memory performance. In the control group, no neural or performance change occurred after the waiting period. CONCLUSION These pilot data point towards a training-related decrease of brain activation, independent of the training approach. Our data highlight the high training-induced plasticity of the child's brain during development.

Resolving diffusion in clay minerals at different time scales: Combination of experimental and modeling approaches

Since no single experimental or modeling technique provides data that allow a description of transport processes in clays and clay minerals at all relevant scales, several complementary approaches have to be combined to understand and explain the interplay between transport relevant phenomena. In this paper molecular dynamics simulations (MD) were used to investigate the mobility of water in the interlayer of montmorillonite (Mt), and to estimate the influence of mineral surfaces and interlayer ions on the water diffusion. Random Walk (RW) simulations based on a simplified representation of pore space in Mt were used to estimate and understand the effect of the arrangement of Mt particles on the meso- to macroscopic diffusivity of water. These theoretical calculations were complemented with quasielastic neutron scattering (QENS) measurements of aqueous diffusion in Mt with two pseudo-layers of water performed at four significantly different energy resolutions (i.e. observation times). The size of the interlayer and the size of Mt particles are two characteristic dimensions which determine the time dependent behavior of water diffusion in Mt. MD simulations show that at very short time scales water dynamics has the characteristic features of an oscillatory motion in the cage formed by neighbors in the first coordination shell. At longer time scales, the interaction of water with the surface determines the water dynamics, and the effect of confinement on the overall water mobility within the interlayer becomes evident. At time scales corresponding to an average water displacement equivalent to the average size of Mt particles, the effects of tortuosity are observed in the meso- to macroscopic pore scale simulations. Consistent with the picture obtained in the simulations, the QENS data can be described using a (local) 3D diffusion at short observation times, whereas at sufficiently long observation times a 2D diffusive motion is clearly observed. The effects of tortuosity measured in macroscopic tracer diffusion experiments are in qualitative agreement with RW simulations. By using experimental data to calibrate molecular and mesoscopic theoretical models, a consistent description of water mobility in clay minerals from the molecular to the macroscopic scale can be achieved. In turn, simulations help in choosing optimal conditions for the experimental measurements and the data interpretation. (C) 2014 Elsevier B.V. All rights reserved.

Controlling for culture-specific response bias using ipsatization and response style indicators: Family orientation in seventeen cultures and two generations

Within-subject standardization (ipsatization) has been advocated as a possible means to control for culture-specific responding (e.g., Fisher, 2004). However, the consequences of different kinds of ipsatization procedures for the interpretation of mean differences remain unclear. The current study compared several ipsatization procedures with ANCOVA-style procedures using response style indicators for the construct of family orientation with data from 14 cultures and two generations from the Value-of-Children-(VOC)-Study (4135 dyads). Results showed that within-subject centering/standardizing across all Likert-scale items of the comprehensive VOC-questionnaire removed most of the original cross-cultural variation in family orientation and lead to a non-interpretable pattern of means in both generations. Within-subject centering/standardizing using a subset of 19 unrelated items lead to a decrease to about half of the original effect size and produced a theoretically meaningful pattern of means. A similar effect size and similar mean differences were obtained when using a measure of acquiescent responding based on the same set of items in an ANCOVA-style analysis. Additional models controlling for extremity and modesty performed worse, and combinations did not differ from the acquiescence-only model. The usefulness of different approaches to control for uniform response styles (scalar equivalence not given) in cross- cultural comparisons is discussed.

Two-Dimensional Crystallisation of Membrane Proteins and Structural Assessment

Two-dimensional (2D) crystallisation of Membrane proteins reconstitutes them into their native environment, the lipid bilayer. Electron crystallography allows the structural analysis of these regular protein–lipid arrays up to atomic resolution. The crystal quality depends on the protein purity, ist stability and on the crystallisation conditions. The basics of 2D crystallisation and different recent advances are reviewed and electron crystallography approaches summarised. Progress in 2D crystallisation, sample preparation, image detectors and automation of the data acquisition and processing pipeline makes 2D electron crystallography particularly attractive for the structural analysis of membrane proteins that are too small for single-particle analyses and too unstable to form three-dimensional (3D) crystals.

Using multiple landscape genetic approaches to test the validity of genetic clusters in a species characterized by an isolation-by-distance pattern

Bayesian clustering methods are typically used to identify barriers to gene flow, but they are prone to deduce artificial subdivisions in a study population characterized by an isolation-by-distance pattern (IbD). Here we analysed the landscape genetic structure of a population of wild boars (Sus scrofa) from south-western Germany. Two clustering methods inferred the presence of the same genetic discontinuity. However, the population in question was characterized by a strong IbD pattern. While landscape-resistance modelling failed to identify landscape features that influenced wild boar movement, partial Mantel tests and multiple regression of distance matrices (MRDMs) suggested that the empirically inferred clusters were separated by a genuine barrier. When simulating random lines bisecting the study area, 60% of the unique barriers represented, according to partial Mantel tests and MRDMs, significant obstacles to gene flow. By contrast, the random-lines simulation showed that the boundaries of the inferred empirical clusters corresponded to the most important genetic discontinuity in the study area. Given the degree of habitat fragmentation separating the two empirical partitions, it is likely that the clustering programs correctly identified a barrier to gene flow. The differing results between the work published here and other studies suggest that it will be very difficult to draw general conclusions about habitat permeability in wild boar from individual studies.

Characterization and age determination of Quaternary volcanism in the southern Ankaratra region (central Madagascar) through novel approaches in luminescence dating

This work introduces two novel approaches for the application of luminescence dating techniques to Quaternary volcanic eruptions: crystalline xenoliths from lava flows are demonstrated to be basically suitable for luminescence dating, and a set of phreatic explosion deposits from the Late Quaternary Vakinankaratra volcanic field in central Madagascar is successfully dated with infrared stimulated luminescence (IRSL). Using a numerical model approach and experimental verification, the potential for thermal resetting of luminescence signals of xenoliths in lava flows is demonstrated. As microdosimetry is an important aspect when using sample material extracted from crystalline whole rocks, autoradiography using image plates is introduced to the field of luminescence dating as a method for detection and assessment of spatially resolved radiation inhomogeneities. Determinations of fading rates of feldspar samples have been observed to result in aberrant g-values if the pause between preheat and measurement in the delayed measurements was kept short. A systematic investigation reveals that the phenomenon is caused by the presence of three signal components with differing individual fading behaviour. As this is restricted to short pauses, it is possible to determine a minimal required delay between preheating and measurement after which the aberrant behaviour disappears. This is applied in the measuring of 12 samples from phreatic explosion deposits from the Antsirabe – Betafo region in the Late Quaternary Vakinankaratra volcanic field. The samples were taken from stratigraphically correlatable sections and appear to represent at least three phreatic events, one of which created the Lac Andraikiba maar near Antsirabe. The obtained ages indicate that the eruptive activity in the region started in the Late Pleistocene between 113.9 and 99.6 ka. A second layer in the Betafo area is dated at approximately 73 ka and the Lac Andraikiba deposits give an age between 63.9 and 50.7 ka. The youngest phreatic layer is dated between 33.7 and 20.7 ka. These ages are the first recorded direct ages of such volcanic deposits, as well as the first and only direct ages for the Late Quaternary volcanism in the Vakinankaratra volcanic field. This illustrates the huge potential of this new method for volcanology and geochronology, as it enables direct numerical dating of a type of volcanic deposit which has not been successfully directly dated by any other method so far.