Macaca radiata. The macaques preferentially used one hand–the ‘preferred’ hand, to pick up the bananas lying on the ground. Lateralities in hand and cheek pouch usage (for both filling and emptying) were positively related with each other, that is, the macaques used the cheek pouch corresponding to the preferred hand predominantly and before the other. Moreover, when the macaques used the non-preferred hand to pick up the bananas, the frequency of contralateral cheek pouch usage was higher than the frequency of ipsilateral cheek pouch usage, that is, the combined structure of hand, mouth, and food did not influence the relationship between laterality in hand usage and laterality in cheek pouch usage. These findings demonstrate laterality in a relatively more involuntary function than those explored previously in any non-human primate species .There can be several factors that are likely to have played a role in the evolution of hand preference in humans and non-human primates, which the existing theories do not consider. There exists a possibility that hand preference in non-human primates evolved from the pre-existing lateralities in more elementary brain functions and behavior, or alternatively, the two coevolved. A basic example can be a hand-mouth command system that could have evolved in the context of ingestion. In the present study, we examined the relationship between lateralities in prehension and mastication processes, that is, hand and cheek pouch usage, in free-ranging bonnet macaques,  The population-level right-handedness in humans  underlying behavioral lateralization.Macaca radiata. In a previous study on hand usage in bonnet macaques In the present study, we examined the relationship between laterality in the prehension and mastication processes in free-ranging bonnet macaques, We conducted semi-manipulative experiments on free-ranging bonnet macaques living close to the Chamundeshwari Temple on top of the Chamundi Hills, Mysore, India (2°14′41″N 76°40′55″E). We studied the hand- and cheek-pouch-usage patterns of 14 macaques: 3 adult males, 3 juvenile males, 7 adult females, and 1 juvenile female. Our experiments were completely non-invasive; we placed bananas on the ground within ∼3 m of the macaque and observed their corresponding hand and cheek pouch usage from distance. Our research work adhered to the American Society of Primatologists (ASP) “Principles for the Ethical Treatment of Non-Human Primates.” Whereas no authorization from a local authority was required, we conducted the present study as part of a larger study approved by the Institutional Animal Ethics Committee (IAEC) at the University of Mysore.We presented the macaques with bananas that were sufficiently large to fill both the cheek pouches and the mouth, whenever both the cheek pouches were empty. Typically, the macaques picked up the bananas, filled one of the cheek pouches  first, then the other; then they emptied one of the cheek pouches and then the other (which does not require the usage of hands). We recorded the hand used by the macaques in the 21 trials to pick up the bananas lying on the ground, and the chronology of filling and emptying both the cheek pouches, whenever they filled both of them . To ensure that each data point represented an event, we recorded only one observation corresponding to the act of picking up a banana. And to eliminate the factors that may have influenced hand preference, we presented the macaques with the bananas only when both the hands were free, and discarded those observations in which the presence of conspecific(s) could have conditioned the manual actions.We determined the z-scores for hand and cheek pouch usage for each of the macaque using the formula: z-score  = [R−(R+L)/2]/√[(R+L)/4] (where ‘R’ and ‘L’ represent the frequency of usage of the right and left hand respectively), and used the obtained z-scores to determine the preferred hand/cheek pouch .We determined the direction and strength of lateral bias in hand usage using the formula: handedness index (HI) = (R−L)/(R+L). The obtained HI values ranged from −1 to +1, with positive values indicating a bias towards right-hand use, and negative values indicating a bias towards left-hand use, while the absolute HI values indicating the strength of the bias. Analogously, we determined the direction and strength of lateral bias in cheek pouch usage viz., laterality index (LI).We used Spearman's rank correlation tests to determine the relationship between HI and LI values. We used a binomial test to compare the frequency of the usage of the two cheek pouches in the observations in which the macaques used the ‘non-preferred hand’  to pick up the bananas .s = 0.825, n = 14, p<0.001; s = 0.810, n = 14, p<0.001; Macaca mulattaPapio anubisPongo pygmaeusIn the present study, we examined the relationship between lateralities  in hand and cheek pouch usage in free-ranging bonnet macaques. Lateralities in hand and cheek pouch usage (for both filling and emptying) were positively related with each other, that is, the macaques used the cheek pouch corresponding to the preferred hand predominantly and before the other. Moreover, when the macaques used the non-preferred hand to pick up the bananas, the frequency of contralateral cheek pouch usage was higher than the frequency of ipsilateral cheek pouch usage, that is, the combined structure of hand, mouth, and food did not influence the relationship between laterality in hand usage and laterality in cheek pouch usage. These findings demonstrate laterality in a relatively more involuntary function than those explored previously in any non-human primate species (e.g., facial expressions in rhesus macaques, Apis melliferaBombus terrestrisHomo neanderthalensis, as found in archeological remains, suggested lateralization of the brain functions associated with tool use involving mouth Asymmetries in elementary brain functions and behavior are turning out to be widespread in both invertebrates and vertebrates Our findings on the relationship between lateralities in hand and cheek pouch usage in bonnet macaques substantiate the possibility of a hand-mouth command system that could have evolved in the context of ingestion, but later could have given rise to hemispheric specializations associated with brain functions and behavior, for example, communication, as has been suggested before


This prospective study aimed to estimate the incidence and associated factors of severe maternal morbidity in southeast Iran. During a 9-month period in 2013, all women referring to eight hospitals for termination of pregnancy as well as women admitted during 42 days after the termination of pregnancy were enrolled into the study. Maternal near miss conditions were defined based on Say et al.'s recommendations. Five hundred and one cases of maternal near miss and 19,908 live births occurred in the study period, yielding a maternal near miss ratio of 25.2 per 1000 live births. This rate was 7.5 and 105 per 1000 in private and tertiary care settings, respectively. The rate of maternal death in near miss cases was 0.40% with a case:fatality ratio of 250 : 1. The most prevalent causes of near miss were severe preeclampsia (27.3%), ectopic pregnancy (18.4%), and abruptio placentae (16.2%). Higher age, higher education, and being primiparous were associated with a higher risk of near miss. Considering the high rate of maternal near miss in referral hospitals, maternal near miss surveillance system should be set up in these hospitals to identify cases of severe maternal morbidity as soon as possible. There are approximately 287,000 preventable maternal deaths annually, of which 99% occur in developing countries . As a seTraditionally, maternal death evaluation has been viewed as key to maternal death prevention . HoweverIn fact, maternal near miss includes those cases in which a woman nearly died but survived during pregnancy or during 42 days after the delivery . Using nThe prevalence of maternal near miss varies among different countries based on health care quality and availability. Nevertheless, in a systematic review using disease-specific criteria, near miss rates have been reported to be between 0.6% and 14.98% .From a global perspective, Iran has been notably successful in reducing maternal mortality. Between 1990 and 2008, Iran has managed to decrease its maternal mortality rate by 80% . The avaThis prospective study encompassed eight hospitals with maternity facilities located in the two large cities of Kerman and Jiroft in southeast Iran. The study was performed in 2013 for a period of nine months. The study protocol was approved by the Ethical Committee of Kerman University of Medical Sciences E.C./90/518). After explaining the study's nature and aims, oral consent was obtained from the participants who all were ensured that their information would remain confidential. First, a list of maternal near miss conditions was prepared based on Say et al.'s recommendations for prospective surveillance of maternal near miss cases [. After et-tests were used to compare the qualitative and quantitative variables between near miss and control groups. A stepwise logistic regression model was used to determine the relationship between underlying variables and near miss ratio. The logistic regression model's goodness of fit was evaluated by the Hosmer-Lemeshow test.Chi-square and independent P < 0.001). University degrees were seen more among near miss women (P = 0.243). The frequency of abortion in the near miss and control groups was 18.6% and 1.6%, respectively (P < 0.001). The frequency of caesarean section in the near miss and control groups was 24.7% and 54.2%, respectively (P < 0.001).During the study period, there were 501 cases of near miss in 19,908 live births (a near miss ratio of 25.2 per 1000 live births). The highest near miss ratio (104.8 in 1000) was observed in the referral  hospital . The meass women . In the In our study group, there were two cases of maternal death. One was a 19-year-old woman diagnosed with intracerebral haemorrhage (ICH); the other was a 28-year-old woman who had undergone curettage due to a failed abortion and died from sepsis because of perforations in the uterus and intestine.The rate of maternal death in near miss cases was 0.40% with a case : fatality ratio of 250 : 1.As shown in In the present study, the near miss ratio was 25.2 per 1000 live births. In the private setting, this rate was 7.5 per 1000, and, in the tertiary care hospital, it was approximately 105 per 1000. The main advantages of this study were its prospective nature and its use of standard criteria for determining near miss cases. Because more than 97% of deliveries in Iran occur in hospitals , the preThe literature shows that maternal near miss ratios vary greatly depending on the population studied, how near miss is defined, and how the study is conducted (prospective versus retrospective) , 19. NeaIn this study, like some other studies , 20, theIn the present study, we found a higher rate of near miss and consequently a lower fatality rate (0.4%). These findings may be derived from our broader definition for near miss events, which combined disease-specific criteria with management-based criteria . In NethIn our study, haemorrhagic disorders (46.1%) and hypertensive disorders (31.9%) were the most common causes of near miss . These rAccording to our logistic regression model, four variables had a relationship with near miss . In oldeAlthough pregnancy complications are to a great extent unpredictable and unpreventable, early awareness of near miss cases can prevent the progress of disease and maternal death . In thisThe present study showed that using data related to near miss cases can provide more comprehensive information when reviewing maternal death cases; therefore, establishing near miss surveillance systems in Iranian hospitals is highly recommended.


The results indicated that BOs associated with male characters in authentic crime videos could later be identified in BO lineup tests well above chance. To further evaluate nosewitness memory, we assessed the effects of lineup size (Experiment 1) and retention interval (Experiment 2), using a forced-choice memory test. The results showed that nosewitness identification works for all lineup sizes , but that larger lineups compromise identification performance in similarity to observations from eye- and earwitness studies. Also in line with previous eye- and earwitness studies, but in disagreement with some studies on odor memory, Experiment 2 showed significant forgetting between shorter retention intervals (15 min) and longer retention intervals (1-week) using lineups of five BOs. Altogether this study shows that identification of BO in a forensic setting is possible and has limits and characteristics in line with witness identification through other sensory modalities.Although canine identification of body odor (BO) has been widely used as forensic evidence, the concept of  Witnesses have an important role in criminal processes e.g., , especiaAlthough identification of culprit body odor (BO) has also been used as evidence in court in many countries e.g., , these iSince witnessing a crime may very well be from the perspective of a victim in close interaction with an offender, the question arises why olfaction has been virtually absent in the forensic field. In fact, humans show the ability to discriminate others’ BO from their own e.g., . They canosewitness paradigm, using a target-present , forced-choice lineup test in an emotional and a neutral condition. The results indicated that BOs associated with male characters in authentic crime videos could later be identified in BO lineup tests well above chance, on par with reports on eyewitness identification. In the second experiment, these findings were replicated by following the standard procedures in the administration of lineups . Whereas performance on target-present trials was highly significant, on target-absent trials performance approached chance level.Pertinent to odor identification in forensics, each individual has a unique “odor print” that is genetically determined e.g.,  and thatsystem variable , we explored two variables that have effects on eyewitness identification performance: lineup size and retention interval (RI). The lineup procedure is characterized as a variable . This mevariable . Workingvariable , may be estimator variable to consider in lineup identification of criminals  lineup memory test, manipulating the lineup size. The forced-choice procedure was chosen for three reasons. First, the procedure targets memory capacity free from decision bias. Second, a previous study . In a later lineup test, participants decided which BO sample out of 3, 5, or 8 total samples was the culprit’s. Since odors may be hard to discriminate , are subBoth experiments were approved by the Ethics Committee of the University of Aveiro, Portugal. Moreover, the guidelines of the Declaration of Helsinki and the standards of the American Psychological Association were followed.M = 21.57, SD = 2.24), while they were in class (non-stressful period). Donors were male  sewn into the armpits of t-shirts previously washed with odorless detergent  from the University of Aveiro volunteered to participate. The participants did not suffer from any mental, neurological, metabolic, or respiratory diseases and were medication free. They were asked to refrain from eating , drinking coffee, or using any products that could interfere with their ability to smell 1 h before testing . Participants and donors signed a written informed consent form, including the right to abort participation at any time, and when applicable were rewarded with course credits.Seventy-three students , lineups with five BOs , and lineups with eight BOs , in which they viewed a 1-min audio-visual presentation (video clip) of a crime involving a man (culprit) and a woman. Instructions were displayed on the screen for 14 s stating: “You will see a real crime captured by a video camera. During the video you will be exposed to an odor collected from the perpetrator of the crime you will be watching.”In a between-subject design, participants were randomly assigned to one of the three conditions: lineups with three BOs  or a theft with a hostage taking (video #2). These two crime videos were selected from not vivid and 9 being very vivid), pleasantness  and arousal (1 being not arousing and 9 being very arousing) and completed a questionnaire assessing trait anxiety  and lineup test, participants rated the video on a 9-point scale in terms of vividness . This forced-choice target-present procedure was chosen in order to obtain a high power and bias-free measure of identification performance. BO samples were presented in wide-mouth glass jars, from left to right, with no time restriction to smell the BO, but without the chance to resample previous BOs. The full instructions stated: “You have a lineup with three/five/eight different BOs in front of you and you will smell all of them from left to right. The BO that you smelled during the video is present in this lineup. You can smell each BO as long as you wish, but you can’t go back and re-smell them. Make a pause of 6 s between each BO. After you smell all of the BOs, indicate your identification response on the sheet, please.”The counterbalancing of the BO samples was arranged in order to assure that the culprit BO was presented in each of the positions of the lineup and that the samples were thawed and refrozen the same number of times within conditions. Due to the number of samples being different between conditions , and since we had two crime videos, the counterbalancing of the BOs was made taking into account the two videos . Thus, we used new sets of odors in each lineup size condition and although the targets were not used as foils, we used different target-BOs within conditions. The interstimulus-interval of 6 s was chosen in an attempt to balance constraints of odor adaptation and working memory capacity .After making their identification, participants were asked to rate their confidence in their decision on a scale from 0 to 100%. Finally, participants were thanked and received further information about the nature of the experiment.not stressed at all to very much stressed, and their state anxiety levels , arousing  and unpleasant . Independent samples t-tests of the crime video ratings indicated no statistically significant difference in the evaluation of the two videos (p > 0.05). They will therefore not be a factor in the following analyses.The ratings of the crime videos clearly indicated that the crimes were experienced as highly vivid (-10), five BOs , and eight BOs  were all above chance level . In order to test the difference in performance between the lineup tests and controlling for the different chance levels we calculated odds ratios. The expected (chance-level) odds for correct responses were 1/2, 1/4, and 1/7 for the conditions with three, five, and eight BOs, respectively, while the observed odds were 23/1, 14/11, and 11/13, respectively.The number of correct responses for the lineups with three BOs  – LN(2))/1.098 = 2.00. A z-score of 2.00 corresponds to a probability (two-tailed) of 4.5%, which means that the probability of getting such a large, or larger, difference between observed and expected odds ratios (based on the difference in chance levels) as in the present case by chance is 0.045.The expected odds ratio when comparing the condition with three BOs with the condition with five BOs was (1/2)/(1/4) = 2 while the observed odds ratio was (23/1)/(14/11) = 18.071. The standard error for the natural logarithm of the odds ratio can be calculated with the formula : square z = 1.862, p = 0.063, for the difference) and when comparing the conditions with five and eight BOs the expected ratio was (1/4)/(1/7) = 1.75 and the observed ratio (14/11)/(11/13) = 1.504 .When comparing the odds for correct responses in the conditions with three and eight BOs the expected odds ratio was (1/2)/(1/7) = 3.5 while the observed odds ratio was (23/1)/(11/13) = 27.182  to the end of the experiment . The correlation between stress levels and performance were low and not significant . Anxiety levels increased from the beginning  to the end of the experiment . State anxiety did not correlate with performance .Several studies in eyewitness have shown that stress and anxiety may impair the identification performance e.g., . In ordepbr(71) = 0.17, p = 0.150].In the 15-min delay between the witness session and lineup test, participants completed a questionnaire assessing trait anxiety STAI-T, , which dpbr(23) = 0.68, p < 0.001; pbr(22) = 0.50, p = 0.01, respectively]. However, this was not verified for the 3-BO lineup condition , probably due to a ceiling effect as all but one participant identified the culprit in this condition.The literature in eyewitness identification often shows that confidence is a poor predictor of accuracy . Early ips > 0.05).The chi-square tests did not show statistically significant differences between women and men for any lineup size condition , while in class for 4 h (non-stressful period). The restrictions given to the donors and the procedures of BO sampling were the same as in Experiment 1.Body odor samples were collected from the armpits of 25 healthy male students from University of Aveiro, aged between 18 and 25 years  from University of Aveiro volunteered to participate. The participants did not suffer from any mental, neurological, metabolic, or respiratory diseases and were medication free. All the behavioral restrictions to reduce exogenous odors were the same as in Experiment 1. Participants and donors signed an informed consent and when applicable were rewarded with course credits.Forty students  and a long retention interval . Each participant viewed a video clip of a crime involving a man (culprit) and a woman. The videos, instructions, procedure and scales were the same used in Experiment 1. The difference was in the LRI condition where participants did the lineup test 1 week after the witness session.In a between-subject design, participants were randomly assigned to one of the two experimental conditions: a short retention interval , arousing  and unpleasant . Independent samples t-tests of the ratings of crime videos indicated no statistically significant difference in the evaluation of the films (p > 0.05). They will therefore not be a factor in the following analyses.As in Experiment 1, the ratings of the crime videos indicated that the crimes were experienced as highly vivid (-4) was significantly above chance level (20%), whereas performance for the LRI  was not .The number of correct responses for the SRI  = 3.75, p = 0.053; Cramer’s φ = 0.31].A chi-square analysis was performed and the effect was marginally significant, indicating increased forgetting over time .Stress levels for SRI and LRI increased insignificantly  to the end of the experiment . There was also no significant correlation between state anxiety and performance .Anxiety levels for SRI and LRI increased insignificantly from the beginning (pbr(38) = -0.07, p = 0.668] with performance.Finally, concerning the trait anxiety STAI-T, , resultspbr(38) = 0.29, p = 0.07] across the two conditions.There was a statistical tendency for a positive correlation between accuracy of identification and level of confidence [ps > 0.05).Chi-square tests did not show significant differences in performance between women and men  for smaller lineups (three BOs). The intrinsic difficulty of discriminating odors  and procIn our second experiment, we investigated the rate of forgetting BOs over time by using two RIs of 15 min and 1-week. In the short RI, the results from Experiment 1 were replicated , showing correct identifications between 50 and 60% of the trials. In the longer RI, performance was lower, as can be predicted from research involving a variety of memory tasks including eyewitness lineup identification . SeveralAs noted above, early investigations indicated that odor memory was unique for its slow forgetting e.g.,  and relaThe identification rate in the two conditions of the current study when using lineup sizes of 5 were as noted 56 and 55%. In the previous study , BOs unkWitness testimony in the judicial system relies solely on eyewitness and earwitness memory e.g., . With thIn these first experiments, we controlled several variables that could interfere with the participants’ performance. For example, donors were given behavioral restrictions in order to allow the use of endogenous BO samples. However, in daily life BOs are influenced by hygiene habits, scented products, food and beverage. In sum, this study shows that identification of BO in a forensic setting is possible and has characteristics in line with witness identification through other modalities, altogether meriting further investigation in this new field. Olfactory memory may turn out to be an interesting forensic tool, either in the identification of culprits or in the recollection of event details. Future avenues of research should entail the effects of emotion during encoding and further testing using the target-absent/target-present approach.LA, SS, CS, and MO designed the experiments; LA, EP, LC, and JF collected the samples (BOs) and collected the data under the supervision of SS and CS; LA, EP, LC, and KS analyzed the data in collaboration with SS, CS, and MO; LA wrote the manuscript with input from all the coauthors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Even in a large volume bariatric centre, bariatric surgeons are sometimes confronted with intraoperative anatomical challenges which force even the most experienced surgeon into a pioneering position. In this video we present how a large gap of approximately 8 cm is bridged by applying several techniques that are not part of our standardized surgical procedure.After creation of a 20 mL gastric pouch we discovered that the alimentary limb could not be advanced further cranially due to a very short a thick jejunal mesentery in a 49 year old male patient during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. By dissecting the gastro-oesophageal junction form the crus, stretching the gastric pouch, transecting the jejunal mesentery, using a retrocolic/retrogastric route, and creating a fully hand-sewn gastrojejunostomy we were able to safely complete the LRYGB. Drains were left near the gastrojejunostomy and the patient was kept nil by mouth for 5 days. On the 5th postoperative day radiographic swallow series were obtained which revealed no sign of leakage. The patient was discharged in good clinical condition on the 6th postoperative day. To date, no complications have occurred. Weight loss results are −31.5 % of the preoperative total body weight.When confronted with a large distance between the gastric pouch and the alimentary limb, several techniques presented in this video may be of aid to the bariatric surgeon. We stress that only experienced bariatric surgeon should embark on these techniques. Inspecting the alimentary limb before the creation of the gastric pouch may prevent the need for such complex techniques.The online version of this article (doi:10.1186/s12893-015-0043-z) contains supplementary material, which is available to authorized users. The Slotervaart Hospital is a teaching hospital in Amsterdam, The Netherlands. We commenced our bariatric program in 2007, gradually expanding in surgical volume about 900 patients annually in 2014. Over the course of these years, many modifications were made to the bariatric program in order to facilitate this expanding number of patients. We have changed our surgical technique, implemented an enhanced recovery, or ‘fast track’ program and trained 2 new residents in to bariatric surgeons, all leading to improvements in patient safety and flatter surgical learning curves [A 20 mL gastric pouch is created with the use of two to three 60 mm linear staplers . At approximately 40 cm proximal to the ligament of Treitz the jejunum is grasped and mobilized to the gastric pouch. The posterior side of the gastrojejunostomy is stapled with a 30 mm linear stapler and the anterior side is hand sewn with an absorbable unidirectional barded 3—0 V-Loc™ suture . At about 150 cm a fully stapled jejunojejunostomy is created with two linear 60 mm staplers. Then the jejunum is transected between the two anastomoses using a 60 mm linear stapler without division of the mesentery. The gastrojejunal anastomosis is tested for leakage with methylene blue through the orogastric tube. There is no routine placement of drains. The orogastric tube is removed at the end of surgery. The patients are allowed a clear fluid diet when fully recovered from anaesthesia. No routine radiographic swallow series are obtained. All patients receive subcutaneous low molecular weight heparin during the first two weeks after surgery as thromboprophylaxis. The patient’s diet is gradually expanded to a full liquid during their admission and continued for two weeks. All patients receive supplementary vitamins and a proton pump inhibitor.2. His past medical history revealed Obstructive Sleep Apnea (OSA), for which he uses Continuous Positive Airway Pressure (CPAP) therapy, Chronic Obstructive Pulmonary Disease (COPD) stage GOLD 2, Post-Traumatic Stress Disorder (PTSD) after a car accident and non-ST elevated myocardial infarction (NSTEMI) for which he underwent a successful percutaneous coronary intervention (PCI) of the ramus circumflexus of his left coronary artery. During his medical screening the patient was diagnosed with Type 2 Diabetes Mellitus (T2DM) ‘de novo’, which was treated with oral medication. The patient’s cardiac, respiratory, and endocrinological function were well assessed prior to surgery and optimally regulated.In December 2012, a 49 year old male was scheduled for laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). At the time of surgery his weight was 138.2 kg with a Body Mass Index (BMI) of 45.1 kg/mDuring the surgery of this patient we where forced to make several deviations from our standardized protocol. The subheadings correspond to the headings of the accompanying video  omentum, the ligament of Treitz is identified. When measuring the jejunum from the ligament of Treitz is becomes apparent that the mesentery is very short. It is not possible to mobilize the jejunum over the transverse colon (antecolic route) and the remnant stomach (antegastric route). The distance between the jejunum is about 8 cm. We measured this distance with the aid of marking on our graspers.In order to create the alimentary limb, the jejunum is transected at the point where the distance to the proximal gastric pouch is the shortest. To further mobilize the alimentary limb, the mesentery is divided with the ultracision harmonic scalpel.A marker stitch  is placed to mark the alimentary limb. Later, this stitch will be used to pull the limb through the retrocolic route.To lengthen the proximal gastric pouch, first the gastro-oesophageal junction is dissected from the crus by transecting the phrenoesophageal ligament on both sides. This technique lengthens the proximal pouch about 2 cm. Because of the traction caused by the gastrojejunostomy, we decided no fixation was needed.Consecutively the pouch is stretched. This is achieved by grasping the pouch on both sides and to pull the pouch caudally for about 1 min. This manipulation of the pouch will gain another 0.5 cm.The retrocolic route is created starting on the caudal side of the mesocolon using the ultracision harmonic scalpel.When completed, the marker stitch is placed in the retrocolic ‘tunnel’. The mesocolon is folded down. Cranially of the mesocolon, the marker stitch is found. The jejunum is retracted by pulling the marker stitch whilst retracting the gastric remnant caudally.It becomes apparent that a stapled anastomosis between the gastric pouch and the jejunum is not preferable due to the foreseen tension on this stapler line. Therefore, we decided to make a full hand—sewn anastomosis with V-Loc™ sutures.A defect is created in the gastric pouch and the jejunum using the ultracision harmonic scalpel.A 34 Ch orogastric tube is passed through the gastric pouch and into the alimentary limb of the jejunum.A running V-Loc™ suture is used to close the anterior part over the tube in order to ensure the patency of the anastomosis.The first leak test with methylene blue through the orogastric tube shows a leak on the right lateral side of the anastomosis.The defect is over sewn with the remaining V-Loc™ sutures.The final leak test revealed no leakage.The creation of the jejuno—jejunostomy went according to our standardized protocol. The mesenteric, mesocolic, and Petersen’s defect were closed using the hernia stapler. A 27 Fr drain was left lateral to the gastrojejunostomy. The patient was kept nil by mouth for 5 days and fed parenteral.During the whole admission, the patient was in a good clinical condition: he was hemodynamically stable and showed no signs of anastomotic leakage. On the 5th postoperative day radiographic swallow series where obtained, which showed no signs of leakage. The drain was unproductive during the whole admission. After the swallow studies the drain was removed. On the 6th postoperative day, the patient was discharged with a full liquid diet. To date, no signs of any complication have emerged . Weight loss results are good: 31.5 % of total preoperative body weight after 12 months. Patients’ blood glucose values returned to normal with discontinuation of all anti-diabetic medications.This video provides a step—to—step guidance on how to solve the rare, but technically demanding intraoperative complication of a large gap between the gastric pouch and the alimentary limb of the jejunum. By dissecting the gastro-oesophageal junction form the crus, stretching the pouch, dividing the mesentery of the jejunum, using the retrocolic/retrogastric route, and the creation of a total hand—sewn gastrojejunostomy were we were able to bridge the gap.et al. [In stark contrast to the reports elaborating the benefits of LRYGB surgery, very little is known about the intraoperative complications. In large trials and reviews conversion rates up to 4.2 % percent are reported , 4, but et al. . This stet al. . The lacAll techniques we describe are not part of our standardized surgical technique and may have disadvantages for the patient. Dissecting the gastro-oesophageal junction from the crus can cause a hiatal hernia, but since the traction in caudal direction from the gastrojejunostomy will prevent the pouch from moving cranially, we thing this is a minor concern. Any form of manipulation of the tissue of the pouch might cause bleeding, ischemia, or tearing. Therefore, stretching of the pouch is a subject of debate. We stress that only experienced surgeons can decide whether or not to apply this technique, based on ‘tissue feel’, and their ability to cope with the possible complications. Division of the mesentery, especially in a situation of increased tension, may result in bleeding, and consequent ischemia of the adjoining jejunum . FurtherBecause of the increased tension on the gastrojejunostomy the risk of leak was high. As a safety measure, we left drains near the gastrojejunostomy, kept the patient nil by mouth and we obtained radiographic swallow series on the 5th postoperative day. It is doubtful if these precautions would have prevented a leak. The aim of these precautions was rather to decrease the severity in case of a leak and to detect a possible leak in an early phase.et al. suggested the formation of the gastric pouch after the inspection and creation of the alimentary limb [From above it is clear that all applied techniques are inferior to our standardized technique and that they should only be used when confronted with an intraoperative event. Maybe even better is the prevention of such situations. This can be done by switching the order of the surgical steps. In our standardized technique the gastric pouch is created at the beginning of the procedure. Schauer ary limb . If we hThis video report shows how a large distance between a newly created gastric pouch and the alimentary limb can be bridged, By dissecting the gastro-oesophageal junction from the crus, stretching the pouch, transecting the mesentery of the jejunum, using a retrocolic/ retrogastric route and creating a hand—sewn anastomosis we were able to bridge a 8 cm gap. All these manoeuvres are not part of our standard surgical technique as they are all associated with adverse patient outcome. We stress that only experienced bariatric surgeons should embark on these techniques. Inspection of the alimentary limb before pouch created might prevent the need for these complex techniques.Written informed consent was obtained from the patient for publication of this video and any accompanying moving or still images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Within health psychology, habit – the tendency to enact action automatically as a learned response to contextual cues – is most commonly quantified using the ‘Self-Report Habit Index’, which assesses behavioural automaticity, or measures combining self-reported behaviour frequency and context stability. Yet, the use of self-report to capture habit has proven controversial. This study used ‘think-aloud’ methods to investigate problems experienced when completing these two measures.Cross-sectional survey with think-aloud study.Twenty student participants narrated their thoughts while completing habit measures applied to four health-related behaviours . Data were coded using thematic analysis procedures.Problems were found in 10% of responses. Notable findings included participants lacking confidence in reporting automaticity, struggling to recall behaviour or cues, differing in interpretations of ‘commuting’, and misinterpreting items.While most responses were unproblematic, and further work is needed to investigate habit self-reports among larger and more diverse samples, findings nonetheless question the sensitivity of the measures, and the conceptualization of habit underpinning common applications of them. We offer suggestions to minimize these problems. Habit is most commonly measured within health psychology via the Self-Report Habit Index, or a combination of self-reported behaviour frequency and contextual stability.The suitability of self-report for capturing automatic processes has been questioned.This is the first study of how people interpret and respond to self-report habit measures.Results show the potential for errors in recalling automaticity, cues, and behaviours.We discuss practical and theoretical challenges to assessing habit in health behaviours.et al., in pressHabits have been defined as dispositions to automatically enact behaviours in specific contexts, acquired by learning context-behaviour associations , recruited via a poster on a UK university campus. No incentives were offered for participation. Psychology students were ineligible for the study to ensure questionnaire interpretation could not be biased by psychology training.To achieve consistency with previous habit studies, which have mostly employed student samples  at this point. We do not view the elaborate wording of the ‘drinking a second alcoholic drink’ items as problematic, given previous SRHI applications specified at a similar level of complexity . Four SRHI items  and were measured on a 1–7 scale on which three points were labelled . Actual past behaviour was measured via a single-item . Four contextual cues were assessed , each via a single statement . A fifth option (‘not applicable – I never do this’), included to allow for the possibility that the behaviour was not relevant, was not selected by any participant for any behaviour.Behaviour frequency × context stability measures incorporated typical and actual past behavioural frequency and contextual cue items. et al. .Descriptive statistics for the habit indices were computed for sample description purposes. BFCS scores were computed by multiplying typical behaviour frequency and each contextual cue score, generating scores between 1 (no habit) and 16 (strong habit). SRHI and SRBAI values represented mean scale scores . The purpose of the analysis was to identify ‘problem segments’ – that is, responses suggesting interpretation difficulties, biased responding, or dissatisfaction with items , and … identity’  and snacking (M = 3.45 days) were the more frequently performed behaviours (Table Commuting by public transport (rs Table . On averSD = 4.99). Of these, 95 problems  related to the SRHI, 32  of which applied to the SRBAI. SRHI items focusing on drinking a second alcoholic drink (30 problem segments) yielded more problems than for drinking alcohol (28), commuting (21), or snacking (19). Across the four behaviours, the SRHI item ‘[Behaviour X is something…] I have no need to think about doing’ was most problematic (16). All SRHI items generated at least one problem, yielding a mean of 1.98 problems per item per behaviour .Eighteen participants (90%) generated at least one problem segment, with 150 problems identified in total .Fifty-five BFCS problem segments  were coded, of which 52 related to cue items and 3 to behaviour. Twenty-five problems were linked to commuting , 11 to snacking , 10 to alcohol (cues), and 9 to (cues to) drinking a second alcoholic drink. Location cue items were most problematic . At least three problems were coded for each BFCS item , and two to sources of bias or error , generated by 12 participants, where the participant was unable to confidently comprehend intended item meanings and could not resolve this by rereading items. The majority (22) of comprehension problems related to the SRHI, particularly those featuring a negative clause . One participant found it difficult to decipher whether ‘drinking a second alcoholic drink’ SRHI items related to generic or context-specific performances:if I'm in a bar, even if it's like three times a year, so… my drinking routine in a bar, yes, I guess. This question is kind of hard to answer. ‘Drinking a second alcoholic drink … is something that belongs to my usual routine.’ I'm not sure. I think it's something that I do frequently, but drinking alcohol is something that I do infrequently, almost never. I consistently drink a second drink In most instances, comprehension problems prompted scale midpoint responses , although one participant deemed disagreement more appropriately .Responses in this category  were those in which the participant understood the gist of an item, but doubted the suitability of their responses. In two instances, uncertainty arose from subjective wording:‘Drinking alcohol is something I do frequently’. That's relative. For some people, once a week is frequent, for some people once a week is infrequent. (P3)‘Drinking alcohol is something I have been doing for a long time’. I've been drinking now for five or six years. I don't know if that's ‘a long time’. (P9)Three participants lacked confidence in reflecting on automaticity , and three people felt unable to reliably identify cues .This category was most populated  and captured instances in which interpretations differed to those intended by researchers. Notable deviations for SRHI items included the belief that an item intended to tap non-awareness in initiating habitual action (‘[Behaviour X is something] … I do without having to consciously remember’) assessed whether behaviour could be reliably recollected . An item designed to capture anomalous and unsettling experiences of non-performance of a habitual response (‘…that makes me feel weird if I do not do it’) was interpreted by four participants to assess awkwardness arising from social exclusion where applied to alcohol consumption:I guess if you're at a party or a pub or when everyone else is drinking, it feels a little weird to be the one person not to do it. (P9)For two participants, an item intended to capture mental efficiency (‘… I have no need to think about doing’), applied to snacking, evoked value judgements around whether people should be more mindful of their diet . One participant interpreted this item to capture personal relevance of the behaviour .Other notable excerpts included one participant reading ‘automaticity’ to specify only innate reflexive actions . Another interpreted an item about the compulsive nature of habitual action (‘… I would find hard not to do’), where applied to commuting, to capture practical difficulties associated with alternative transport options .Behaviour frequency × context stability cue items, which are designed to capture the contexts in which a habitual action commences, evoked most misinterpretations for commuting. Participants variously interpreted ‘commuting’ to begin when leaving home, when waiting for a bus or train, or when aboard the vehicle:[I am in the same physical location] practically always, if it's from home. (P19)Yeah, I always get the bus at the same place. (P7)The whole point of public transport is to get you from one physical location to another, so I'd say never, I'm always moving. (P3)One participant deviated from intended meanings by answering some items in relation to other people rather than herself:‘Drinking alcohol is something that would require effort not to do’. That is a tough question, ‘cause I'm answering it objectively. For some people, where alcohol becomes a kind of … social tool, custom or norm, that'd be hard not to do. (P16)This category encapsulated 27 instances  in which participants provided responses based on contextual information not present within the item, or otherwise voiced concern over a lack of contextualization. The former resulted in differences between participants in interpretations of the same item, for example ‘Drinking alcohol is something I do automatically’:Well, being in a social situation, when I'm going to be with friends, it's kind of automatic, in a sense. (P17)I guess I'd slightly agree. If I go to a pub or club or something like that, I do it automatically then. It's not something like, when I get home, I'd have a drink right away, but it's automatic when I'm in a pub. (P9)Contextual qualification was observed across all behaviours, even for items relating to drinking a second alcoholic drink, which explicitly specified location and preceding action cues:‘Drinking a second alcoholic drink … is something I would find hard not to do’. A bit, I guess, yes, when everyone else is drinking. (P6)Some participants gave neutral responses to items deemed insufficiently contextualized, despite indicating that they (dis)agreed with statements in certain settings. For example, a participant visiting the UK stated:‘Eating unhealthy snacks is something I do frequently’. I'd say neither agree nor disagree. Now that I'm living on my own, I don't do that frequently, but when I'm … back home, I do it much more frequently ‘cause I know there'll be lots of chips and cookies around. (P9)All four segments  coded into this category arose from SRHI items relating to ‘drinking alcohol’, reflecting concerns that agreement with statements about habitual drinking would portray participants in a negative light .This category  captured difficulties participants experienced in accurately recalling their behaviour (11 responses) or cues (2), for example:‘On how many of the past 7 days did you eat unhealthy snacks?’ I don't know, I can't count, so let's say three or four days, I don't know. (P17)‘When I eat unhealthy snacks, I am in the same physical location’. I don't remember where I eat unhealthy snacks. (P13)et al., This study used ‘think-aloud’ methods to investigate potential difficulties in participants’ responses to two self-report measures of habitual action – the SRHI  causing difficulties for some. Alternatively, context-free SRHI items might be combined with BFCS cue stability indicators . It seems feasible that each, but not necessarily all, of these may proceed automatically in response to contextual cues ; boarding the bus may be automatic, but finding a seat may require reasoned deliberation. Detailed specification of behavioural targets is needed to enhance the conceptual clarity of applications of habit measures and to avoid conflating automatic and reflective processes. This in turn raises important questions about the application of habit within health psychology. Habit has traditionally been used to refer to the cognitive mechanism by which simple actions, such as pulling levers, proceed reflexively and in a fixed sequence Tolman, . Yet, stet al.  echoes results from previous ‘think-aloud’ studies; for example, French et al.  found 9% et al., . Further et al., . This prOur study suggests that multiple problems can arise in participants’ responses to the two most commonly used self-report habit measures. Although problems were only expressed in a minority of responses, it would seem prudent for researchers to take steps to mitigate such problems where possible.


Malnutrition is locked in a vicious cycle of increased mortality, poor health, impaired cognitive development, slow physical growth, reduced learning capacity, inferior performance, and ultimately lower adult work performance and productivity. The consensus of global scientific evidence indicates that lowering the rates of malnutrition will be an indispensable component of any successful program to raise the quality of human capital and resources. This study used a “consequence model” to apply the coefficient risk-deficit on economic losses, established in the global scientific literature, to Cambodian health, demographic, and economic data to develop a national estimate of the value of economic losses due to malnutrition. The impact of the indicators of malnutrition analyzed represent a burden to the national economy of Cambodia estimated at 266 million USD annually (1.7% of GDP). Stunting is reducing the Cambodian economic output by more than 120 million USD, and iodine deficiency disorders alone by 57 million USD. This economic burden is too high in view of Cambodia’s efforts to drive economic development. The government should rapidly expand a range of low-cost effective nutrition interventions to break the current cycle of increased mortality, poor health and ultimately lower work performance, productivity, and earnings. In the late nineties, in a regional Asian effort to advocate on the importance of malnutrition, the United Nations Children’s Emergency Fund (UNICEF) and the Asian Development bank assessed the impact of malnutrition on the economy in seven countries. It was concluded that malnutrition, with its insidious effect over the life span of a child, will cost the economies at least 3% of their gross domestic product (GDP) . MalnutrCambodia’s expanding economy, along with rising incomes and easier access to food, is expected to contribute to the reduction of currently high rates of malnutrition, as reported in 2010 . AccordiThe 2014 CDHS  shows thRegardless of the recent attention in the national policy dialogue and strategies, the nutrition agenda remains under-resourced both by the government and donors, constraining the much-needed scale-up of a life-cycle approach, particularly towards children under 5 years of age. The aim of this article was to re-examine and update the economic implications of malnutrition in Cambodia and lay the ground work for a general consensus among Government and donors on the need to invest in nutrition.The assessment explored the economic losses associated with 14 nutrition indicators collected during the 2014 Cambodian Demographic Health Survey   via 4 diThe scale of child mortality emerging from malnutrition is hidden in a negative synergy of malnutrition, infection, disease, and premature death of children. Except for rare cases of kwashiorkor or nutritional marasmus, malnutrition is rarely listed as the cause of death. However, malnutrition is a distinct, measureable and often significant contributing factor to child mortality and is globally recognized as the underlying cause of up to 45% of all child death . EstimatThis pathway applies coefficients of risk for mortality for specific maternal  and height) and child  nutrition indicators. Those relative risks used in the global scientific literature see  have beeFor pathway 1, to estimate the number of deaths attributable to maternal and child malnutrition, the following algorithm was used ,11: NumWith Population attributable risk, the Population Attributable Risk (PAR) is a function of the prevalence of the nutrition indicator along with the severity of the mortality risk as expressed by the Relative Risk RR: see . It is cThe estimated value of workforce lost to child mortality was then estimated. This value is simply derived as a lost workforce—by taking a discounted net present value (NPV) of future lost earnings. The NPV includes a delayed earnings stream that presumes entry into the workforce at an average of 15 years of age—a delay ranging from 15 years for perinatal and neonatal deaths to an average of 13 years for the 6–59 months old cohort. Furthermore, this economic perspective attributes an economic value only to the 82.6% of children who would be projected to participate in the labor force as adults. In other words, this economic calculation attributes no value at all to approximately 17% of these child deaths who are not projected to participate in the labor force and be economically active. Average Earnings, $US 1,253/year; based on $US 177 per month per household and average number of workers per household estimated at 1.7; Labor Force Participation, All: 82.6%, Male: 87.9% and Female: 77.5% ; Net PreChildren, even mildly or moderately undernourished, score poorly on tests of cognitive functions, psychomotor developments, and fine motor skills. With lower activity levels, they interact less frequently with their environment and thus fail to acquire physical and intellectual skills at normal rates. These early childhood deficits determine to a large extent the ability to capitalize on educational opportunities and later employment opportunities, resulting in an adult productivity deficit. There is substantial evidence that after correction for poverty, nutrition has independent and additive impacts on child growth, cognition, and development . PathwayThe general algorithm for annual losses due to depressed future productivity (DFP), mixing global and national parameters, was applied ,11 to eaFor stunting, a 19.8% deficit see  in earniFinally, for iodine deficiency disorders (IDDs), substantial literature links IDD to a deficit of IQ points—which is in turn linked to earnings deficits of about 9.6%. This coefficient of deficit is then applied only to the 13% of a CDHS national sample that indicated severe iodine deficiency.Weakness, fatigue, and lethargy brought on by anemia result in measurable productivity deficits in manual labor. Aerobic capacity, endurance, and energy efficiency are compromised by 10%–50% . Our anaThe general algorithm for annual losses due to depressed current productivity (DCP): Multiple reviews have associated several nutrition factors to the increase or decrease of diarrhea and acute respiratory infection (ARI), the two main morbidities assessed in the Cambodia Health Monitoring Information System. In this paper, we have assessed the increase of healthcare expenditure due to zinc deficiency, none sub-optimal breastfeeding and low birth weight due to maternal nutrition status.et al. derive a pooled and prevalence adjusted RR of 2.85 for diarrhea and a RR of 2.07 for ARI [et al., or RR 1.93 for diarrhea [A wealth of literature has documented the association of suboptimal breastfeeding and increased morbidity from acute respiratory infection and diarrhea . For exa for ARI . Applyindiarrhea .Based on the prevalence from CDHS data and distinct infection-specific risk from the literature, several Population Attributable Risks (PAR) were calculated to derive the number of cases attributable to each infection (diarrhea and ARI) and nutrition indicators. The sum of these eight individual projections gave the total excess cases to be treated at health facilities level due to none–suboptimal breastfeeding and zinc deficiency. For low birth weight, 31% of the cases were associated with maternal nutrition . Finally, to estimate the cost of those excess cases, we have used the average pediatric case-costs from the 2012 Cambodia Hospital costing and financial management study .The impact of the indicators of malnutrition analyzed in the report represent a burden to the national economy of Cambodia estimated at more than 260 million USD annually. This amount represents 1.7% of the estimated 2013 Gross Domestic Product (GDP) from the Ministry of Economy and Finance (15.8 billion USD). Maternal malnutrition and suboptimal breastfeeding along with child underweight, wasting, zinc, and vitamin A deficiencies bring a higher risk of death to children less than 5 years of age, ranging from about one-third to more than 10 times the risk of well-nourished children . These rDuring the first six months of life, non-exclusive breastfeeding is associated with about 60% of infant deaths . As overPresuming an entry into the workforce at average age of 15 years, the total economic losses from emerging child deaths is approximately 62 million USD  utilization of health facilities and (ii) expenses for health services. Children 6–24 months of age not benefiting from adequate breastfeeding practices and children 6–59 months old with zinc deficiencies suffer 2.6 million excess preventable cases of diarrhea and respiratory illness. These cases, together with low birth weight and birth defects associated with maternal nutrition status, result in excess costs to the health system and to families of approximately $9.6 million annually .Most of Cambodia’s children face higher than normal risks of dying before their fifth birthday. More than four thousand deaths annually—nearly one-third of all child mortality—is linked to their mother’s nutrition status and breastfeeding behavior, along with child underweight or vitamin and mineral deficiencies. The present value of this lost future workforce is estimated at more than 60 million USD annually (with 3% discount rate). 2.6 million annual cases of diarrhea and respiratory infection among children are attributed to poor breastfeeding practices and zinc deficiencies, resulting in excess costs to the health care system and individual families reaching nearly $8.6 million (with 3% discount rate). Finally, children with less than normal height, iron deficiency or iodine deficiencies suffer deficits in mental and physical development, perform less well in school and consequently, will be less productive as adults, reducing GDP by 186 million USD per year (with 3% discount rate).In total, according to the 2014 CDHS  and depeThe findings of our assessment represent an improvement of 100 million USD less lost in comparison to the previous calculation done with indicators from the 2010 CDHS ,7. One oMost of the projected losses (45%) are linked to stunting. Similar findings were observed in Albania, where stunting represented also approximately 50% of the economic losses . ChildhoEven if in Cambodia, less than 3% of the 266 million USD in annual economic burden is associated with acute malnutrition requiring in-patient or out-patient clinical life-saving medical care, it is essential to continue the efforts to treat those affected children. Evidence suggests episodes of wasting negatively affect linear growth and, therefore, undermine child growth and development . During As highlighted in As highlighted in the recent global nutrition report , scalingLimitations to the conceptual model: Converting indicators of malnutrition to an economic activity and attaching a monetary value to that economic activity could be interpreted and analyzed in many different ways. First, monetizing the consequences of malnutrition is dependent on evolving evidence bases, complex methodologies and national health, demographic and economic statistics of uneven quality; Second, many factors beyond individual physical and intellectual potential determine earnings or work performance. Workplace incentives, available technology, and sense of opportunity all affect how increased human potential translates into actual improved productivity. In addition, productivity growth was not considered in the model, even if we can speculate that today’s children are likely to be much more productive in their working life than their parents are today; Finally, benefits of improved nutrition extend beyond the workplace to a range of “voluntary” activities, including parenting and household activities to educational improvement, entrepreneurial pursuits, and community participation. In a world where improvement in nutrition, health, and subsequent productivity will emerge mainly from individual choices and behaviors, the significance of these “voluntary” activities cannot be overstated. For all these reasons and more, the margin of error is large and the calculations should be considered as an order of magnitude. These are projections to focus and facilitate policy discussion and present a solid and conservative case for policy discussion. Therefore, data judgments or assumptions are consciously and consistently “biased” to minimize the impact of malnutrition. Consequently, conclusions drawn may be considered conservative low-end estimates.i.e., education, sanitation, and poverty reduction schemes—to address malnutrition and to attract further investment so that nutrition specific and nutrition sensitive programs can be implemented in the most synergetic and optimal way. Only through this joint effort and focus can Cambodia further thrive and prepare a healthy population and labor force.This article used a proven methodology on how to calculate the economic burden of malnutrition in regard to 14 key nutrition indicators for Cambodia. It showed that Cambodia is losing approximately 266 million USD per year by not addressing malnutrition, in particularly stunting and iodine deficiency. The study does not suggest easy wins for addressing those two nutrition problems, but it suggests and urges the government of Cambodia to undertake a thorough review of its current policies and directives to assess if they address malnutrition in the most optimal way. Cambodia’s efforts to expand its economic growth is hindered by a sub-optimal labor force and high avoidable costs for the health care system. It is key to reach out and link with other sectors—


Most people want to die at home but only half do. Supporting patients in rural locations is challenging. Video calls such as Skype, might help but are not routinely used; we should consider learning needs to increase uptake and ensure effective use. We aimed to identify learning needs of healthcare professionals (HCPs) in using video calls to support patients (and their carers) to die at home.Face-to-face workshops were held in five Southwest England locations. Participants discussed advantages, disadvantages, scenarios for use, and the learning needs of video call users. Ideas were documented on flipcharts and discussions audio-recorded. The 116 participants included nurses, allied HCPs, doctors and previously bereaved volunteers. Lists of advantages, disadvantages, scenarios and learning needs were compiled and circulated to participants. In a subsequent online workshop, 21 participants ranked seven groups of learning needs in priority order.Most participants thought video calls could be used to advantage in many end-of-life scenarios, especially in rural areas. Seven themes, covering 59 learning needs for HCPs, were identified (in priority order): (i) confidence and technical ability in using video calls; (ii) being aware of how video calls fit into clinical practice; (iii) managing video calls; (iv) communication skills on ‘camera’; (v) understanding how patients and families may be affected by video call use; (vi) presenting video calls as an option to patients and families to assess their readiness; (vii) normal professional skills that become essential for effective video calls.Although almost ubiquitous, video call software is not routinely and effectively used in British clinical practice. Supporting patients and families at end-of-life is one example where it could be used to advantage, but clinicians need to plan and practise before using it in real situations. Learning needs were identified that could be developed into learning modules and/or courses.The online version of this article (doi:10.1186/s12909-016-0657-6) contains supplementary material, which is available to authorized users. Three out of four people want to die at home  but natiActual place of death gives no indication on whether the death was comfortable or dignified. In the National Survey of Bereaved People (VOICES): 2014, just over half surveyed said that services definitely worked well together for patients who had spent the last three months at home, so coordination of community care can be improved . Video cUsing video calls in clinical practice is not new  but ofteWe conducted face-to-face focus group workshops and thematically analysed the discussions. In a subsequent online workshop, participants ranked the themes identified from the face-to-face workshops. Additional file Five face-to-face workshops were held between May and July 2015 in locations corresponding to the main adult hospices in Cornwall and Devon. In September 2015, an online workshop was conducted inviting participants from the UK. Ethical approval was not required for this service improvement study  then helped with all the workshops. Personal contacts were used to ‘snowball’ to find people across Devon and Cornwall who might be interested to attend. A wide range of HCPs were invited to participate in the workshops Table . An examWe introduced the topic of video calls to participants and set the parameters for discussion. For example, we assumed current or ‘near future’ technology and although we acknowledged that internet connection was not always good in some rural areas, we made the assumption that inequity of provision was ‘another conversation’. We assumed that video calls provide more information than telephone calls but less than face-to-face visits.Depending upon the number of participants attending each workshop, we facilitated two or three groups per session aiming for 8–12 participants per group. The same three facilitators  with agreed procedures were used for all workshops. The discussions focused on whether video calls could be used to support patients in the last six months of their lives to die at home. Home was classified as their own home or a care home. Each workshop had two sessions. First, participants discussed advantages, disadvantages, learning needs and research and development needs of using video calls. During this first session, previously bereaved volunteers were kept separate from HCPs to allow them to ‘settle in’ as for some group discussions like this may have been new and we also wanted to ensure that they were ready to discuss issues around end-of-life without feeling too upset about their own loss. Secondly, participants discussed scenarios, learning needs and research and development needs of using video calls. During this second session, participants were mixed to give similar balance of volunteers and HCPs in each group.Two methods of data collection were used: (i) participants were asked to note down key points from the discussions and post them onto flipcharts under the relevant section; (ii) sessions were audio recorded. Also detailed notes were taken by one of the team members (DT) in her workshops. After each workshop the facilitators discussed whether that workshop brought up any new topics. All the notes posted onto flipcharts were typed up under the relevant sections. Audio recordings were listened to (but not transcribed) for clarification purposes. A preliminary list, with themes identified under each section, was emailed to workshop participants asking for any further comments.In a subsequent online workshop, learning needs from the face-to-face workshops were presented using seven themes. Participants were asked to rate whether or not a ‘typical’ HCP dealing with end-of-life had these skills already or would need training to develop them. Ratings were converted into scores from one , through to four . Themes were then ranked in order based on the mean score.In total, 137 people (plus five team members) participated in both face-to-face and online workshops  the flip charts and ‘post-its’ of main points that were written by the groups as they discussed the issues, (b) detailed notes taken by one of the team members (DT) in her workshops, (c) the audio tapes when clarification or confirmation was needed. After each workshop the facilitators also discussed whether that workshop brought up any notable new topics. This is perhaps not as rigorous as transcribing each tape but we are fairly sure that we have not missed any major ideas. Two authors  reviewed the data and agreed on the final list of advantages, disadvantages, scenarios, and learning needs. This list was reviewed by others in the team and was the basis of the online workshop so seems to have some face validity with this wider audience.The 59 learning needs for HCPs presented in this report could be used to develop learning materials either some self-learning package or, more likely, some form of course. Communication skills’ training is mandatory for palliative care HCPs because it can be nurtured and improved . Use of We envisage that new learning needs and scenarios will become apparent as the technology is used more widely. However, the learning needs identified here will serve as a good starting point. These learning needs may diminish as people start to use it in their everyday lives; nevertheless many organisations still run professional development courses in the use of telephone .We present detailed learning needs but further work is needed to design suitable learning resources and we are currently considering how to take this forward. For example, our seven themes could be condensed into four learning outcomes: (i) HCP introduces the idea of video calls; (ii) HCP preparation before the video call; (iii) HCP conducts the video call; (IV) HCP reflects on the video call and the information gained or not. Jelle van Gurp et al.  have devAlthough almost ubiquitous, video call software is not routinely and effectively used in British clinical practice. Supporting patients and families at end-of-life is one example where it could be used to advantage, but clinicians need to plan and practise before using it in real situations. We have identified areas 59 learning needs in seven themes. Further work is needed to design suitable learning resources. The seven themes may be condensed into four groups focussing on introducing, preparing, conducting, and reflecting on the video call.The study was funded by Health Education South West Innovation Fund. As an educational innovation and service improvement study it did not require approval from a Research Ethics Committee. Further information on this is given in the Additional file


ETCO2 is currently the only parameter proven to correlate with the likelihood of return of spontaneous circulation (ROSC), although the prediction of long-term outcome based on ETCO2 values has not been established [2 adequately, invasive airway management is necessary and measured values are influenced by different lung pathologies.The goal of cardiopulmonary resuscitation (CPR) is to preserve the pre-arrest neurological state by maintaining sufficient cerebral blood flow and oxygenation, but the predictors thereof remain largely unknown. Despite recent attempts to improve the quality of basic and advanced life support, no monitored link to the neurological and physiological response of these CPR efforts has been established. The difficult decision to end pre-hospital resuscitation efforts is currently based on the circumstances of cardiac arrest, length of resuscitation efforts (if available), knowledge of pre-morbid physiological reserves, and (if present) end-tidal carbon dioxide  measures the regional difference between oxygenated and deoxygenated hemoglobin, which expresses the difference in oxygen supply and demand. It determines cerebral tissue saturation non-invasively and independent of pulsatile flow. Müllner and colleagues  were theAlmost 20 years after the first published study on cerebral saturation monitoring during CPR, a revival of cerebral saturation measurement during CPR is taking place. Recent published research measures cerebral saturation in patients with ongoing CPR at arrival to the emergency department, but different cerebral saturation devices and different methods for analysis of NIRS data are used. The latest research on NIRS in the CPR setting focuses on two main questions.Firstly, can cerebral saturation values predict ROSC or neurological outcome? Ito and colleagues  observedThe second question recently addressed is whether cerebral saturation values can guide CPR efforts. Cerebral saturation measurements are probably more useful as a dynamic measurement instead of a static, single value. Hence, low cerebral saturation values could be interpreted as a need for interventions aimed at improving cerebral oxygenation during CPR. Sustained low cerebral saturation values, despite these interventions, could indicate futile CPR efforts. It has been noted that no patients with a mean cerebral saturation of less than 30% achieved ROSC . In contIn conclusion, preliminary data suggest that monitoring of cerebral saturation during CPR seems a likely predictor of both ROSC and neurological outcome and that it might have a role guiding CPR interventions. Although the current knowledge, obtained from small observational studies, is limited, both the further development of NIRS devices and the likely execution of well-designed large blinded observational trials, particularly in the difficult environment of out-of-hospital CPR, bode well for the future. A real-time monitoring tool providing vital information on the neurological and physiological response to CPR efforts and with predictive value for neurological outcome seems close at hand.


Video games contain elaborate reinforcement and reward schedules that have the potential to maximize motivation. Neuroimaging studies suggest that video games might have an influence on the reward system. However, it is not clear whether reward-related properties represent a precondition, which biases an individual toward playing video games, or if these changes are the result of playing video games. Therefore, we conducted a longitudinal study to explore reward-related functional predictors in relation to video gaming experience as well as functional changes in the brain in response to video game training. Fifty healthy participants were randomly assigned to a video game training (TG) or control group (CG). Before and after training/control period, functional magnetic resonance imaging (fMRI) was conducted using a non-video game related reward task. At pretest, both groups showed strongest activation in ventral striatum (VS) during reward anticipation. At posttest, the TG showed very similar VS activity compared to pretest. In the CG, the VS activity was significantly attenuated. This longitudinal study revealed that video game training may preserve reward responsiveness in the VS in a retest situation over time. We suggest that video games are able to keep striatal responses to reward flexible, a mechanism which might be of critical value for applications such as therapeutic cognitive training. Over the last decades, the video gaming industry has grown into being one of the biggest multimedia industries in the world. Many people play video games on a day-to-day basis. For example in Germany 8 out of 10 people between 14 and 29 years of age reported to play video games, and 44% above age 29 still play video games. Taken together, based on survey data approximately more than 25 million people above 14 years of age (36%) play video games in Germany .It seems as if human beings have a genuinely high motivation to play video games. Most frequently video games are played for the simple purpose of “fun” and a short-term increase in subjective well-being . Indeed,Due to the high use, video games have come into the research focus of disciplines such as psychology and neuroscience. It has been shown that training with video games can lead to improvement in cognitive performance , and in precondition, which biases an individual toward playing video games or if these changes are the result of playing video games.The underlying neurobiological processes associated with video gaming have been investigated with different imaging techniques and experimental designs. A raclopride positron emission tomography (PET) study by In summary, video games are quite popular and frequently used. One reason for that might be that video gaming may fulfill general human needs . SatisfiHere, we conducted a longitudinal study to be able to explore reward-related functional predictors in relation to performance and experience in the game as well as functional changes in the brain in response to video game training. We used a successful commercial video game, because commercial games are specifically designed to increase subjective well being  and therFifty healthy young adults were recruited via newspaper and internet advertisements and randomly assigned to video game training group (TG) or control group (CG). Preferably, we recruited only participants that played little or no video games in the last 6 months. None of the participants reported to play video games more than 1 h per week in the last 6 months  and never played the training game [“Super Mario 64 (DS)”] before. Furthermore, the participants were free of mental disorders , right-handed, and suitable for the MRI scanning procedure. The study was approved by the local Ethics Committee of the Charité – Universitätsmedizin Berlin and written informed consent was obtained from all participants after participants were fully instructed on the procedures of the study. Data of anatomical gray matter maps of these participants have been previously published .n = 25, mean age = 23.8 years, SD = 3.9 years, 18 females) was instructed to play “Super Mario 64 DS” on the “Nintendo Dual-Screen (DS) XXL” handheld console for at least 30 min per day over a period of 2 months. This extremely successful platformer game was chosen based on its high accessibility for video gaming naïve participants, as it offers a well-suited balance between reward delivery and difficulty and is popular among male and female participants. In the game, the player has to navigate through a complex 3D environment using buttons attached to the console used for movement, jumping, carrying, hitting, flying, stomping, reading, and character specific actions. Prior to the training, participants were instructed on general control and game mechanisms in a standardized way. During the training period, we offered different types of support  in case frustration or difficulties during game play arose.The TG  had no task in particular but underwent the same scanning procedure as the TG. All participants completed an fMRI scan at the beginning of the study (pretest) and 2 months after training or after a passive delay phase (posttest). The video game training for the TG began immediately after the pretest measurement and ended before posttest measurement.The no-contact CG  and sent the electronic data files via email to the experimenters. The accomplished game-related reward (stars collected) was objectively assessed by checking the video gaming console after training period. The maximum absolute amount of stars was 150.To investigate reward anticipation, a slightly modified slot machine paradigm was used that evoked strong striatal response . ParticiFigure 1).At the beginning of each trial, the wheels did not move and gray bars indicated the inactive state. When these bars turned blue , the participant was instructed to start the machine by pressing a button with the right hand. After a button press, the bars turned gray again (inactive state) and the three wheels started to rotate vertically with different accelerations . When the maximum rotation velocity of the wheels was reached (1.66 s after button press) the color of the bars turned green. This color change indicated that the participant could stop the machine by pressing the button again. After another button press, the three wheels successively stopped rotating from the left to the right side. The left wheel stopped after a variable delay of 0.48 and 0.61 s after the button press, while the middle and right wheel were still rotating. The second wheel stopped after an additional variable delay of 0.73 and 1.18 s. The right wheel stopped rotating after the middle wheel with a variable delay of 2.63 and 3.24 s. The stop of the third wheel terminated the trial and a feedback about the current win and the total amount of reward was displayed on the screen. For the next trial, the button changed from gray to blue again and the next trial started after a variable delay that ranged between 4.0 and 7.73 s and was characterized by an exponential decreasing function , 20 loss trials (XXY or YYX), and 20 early loss trials . Participants started with an amount of 6.00 euro representing the wager of 0.10 euro per trial  and gained 0.50 euro per trial, when all fruits in a row were of the same identity (XXX or YYY); if not, participants did not win  and the wager was subtracted from the total amount of money. Participants had no influence on winning or losing and the participants won the fixed amount of 10.00 euro  at the end of the task. The participants were instructed to play the slot machine 60 times and that the aim in each trial is to get three fruit of the same kind in a row. Further, participants practiced the slot machine task before entering the scanner for 3–5 trials. No information was given that the task was a game of chance or any skill was involved.∗-weighted gradient echo planar imaging (EPI) with the following parameters: 36 slices, interleaved ascending slice order, time to repeat (TR) = 2 s, time to echo (TE) = 30 ms, field of view (FoV) = 216 × 216, flip angle = 80°, voxel size: 3 mm × 3 mm × 3.6 mm. For anatomical reference, 3D anatomical whole brain images were obtained by a three-dimensional T1-weighted magnetization prepared gradient-echo sequence .Magnetic resonance imaging scans were conducted on a three Tesla Siemens TIM Trio Scanner , equipped with a 12 channel phased array head coil. Via a video projector, the slot machine paradigm was visually presented via a mirror system mounted on top of the head coil. Functional images were recorded using axial aligned T2Magnetic resonance imaging data was analyzed using Statistical Parametric Mapping software package . EPIs were corrected for acquisition time delay and head motion and then transformed into the stereotactic normalized standard space of Montreal Neuroimaging Institute using the unified segmentation algorithm as implemented in SPM8. Finally, EPIs were resampled (voxel size = 3 mm × 3 mm × 3 mm) and spatially smoothed with a 3D Gaussian kernel of 7 mm full width at half maximum.T-contrast images were entered into a flexible factorial analysis of variance (ANOVA) with the factors group (TG vs. CG) and time (pre- vs. posttest).A two-stage mixed-effects general linear model (GLM) was conducted. On single subject level, the model contained the data of both fMRI measurements, which was realized by fitting the data in different sessions. This GLM included separate regressors per session for gain anticipation (XX_ and YY_) and no gain anticipation (XY_ and YX_) as well as the following regressors of no interest: gain (XXX and YYY), loss (XXY and YYX), early loss , button presses (after bar changed to blue as well as green), visual flow (rotation of the wheels), and the six rigid body movement parameters. Differential contrast images for gain anticipation against no gain anticipation (XX_ vs. XY_) were calculated for pre- and posttest and taken to group level analysis. On the second level, these differential p < 0.05, when using a minimum cluster size 16 adjacent voxels with a statistical threshold of p < 0.001. According to a meta-analysis by post hoc analysis within this brain area using a region of interest (ROI) analysis. To this end, we used a literature-based ROI for the VS . For the contrast TG > CG, a stronger activation in the right supplementary motor area  = 9, 23, 49] and for CG > TG a stronger activation in the right pallidum  = 5.66, MNI-coordinates [x y z] = 27, 8, 7) were observed. Both regions are probably not associated to reward-related functions as shown in the meta-analysis by At pretest, during the slot machine task in both groups, gain anticipation (against no gain anticipation) evoked activation in a fronto-striatal network including subcortical areas , prefrontal areas , and insular cortex. Additionally, increased activation in the occipital, parietal and temporal lobes was observed. All brain regions showing significant differences are listed in supplementary Tables M = 4.43, SD = 0.96), frustration  and video gaming desire  were averaged across the 2 months. Participants collected 87 stars (SD = 42.76) on average during the training period.To test the hypothesis of the predictive properties of striatal reward signal toward video games, the ventral striatal signal was individually extracted using the literature-based ROI and correlated with questionnaire items as well as game success, which was assessed by checking the video gaming console. Due to a lack of compliance of participants, weekly questionnaire data of four participants was missing. Weekly questions about experienced fun (p < 0.006), none of the correlations were significant. Neither video gaming desire  nor frustration  nor accomplished game-related reward  were correlated with reward-related striatal activity. Interestingly, when using uncorrected significance threshold experienced fun during video gaming was correlated positively with the activity during gain anticipation in the right VS  and a trend was observed in the left VS  as shown in Figure 2 (bottom right panel). However, when applying Bonferroni correction to this exploratory analysis, also the correlations between experienced fun and ventral striatal activity remained non-significant.When applying Bonferroni correction to the calculated correlations .We further conducted a control analysis to investigate, whether this finding is specific for the VS. We correlated the same behavioral variables with the extracted parameter estimates of the Heschl’s gyri (primary auditory cortex). The analysis revealed no significant correlation  = 5.7, p = 0.021]. ROI-analysis in the control region (Heschl’s gyri) was non-significant. Additional t-tests revealed a significant difference between the time points within the CG group  as well as a significant difference between the groups at posttest . Results for the interaction group by time are summarized in Table 1 and are illustrated in Figure 3.Analysis of gain anticipation against no gain anticipation during the slot machine task at posttest revealed activation differences in the TG in the same fronto-striatal network as observed at pretest . However, video gaming behavior in the CG might have changed and could have affected the results. Future studies should include active control groups and assess video gaming behavior during the study period in detail.In this study we focused on the VS. Nonetheless, we observed a significant training-related effect also in the insular cortices, SMA, and precentral gyrus. A recent meta-analysis by From a psychological view, joyful video games provide highly effective reward schedules, perfectly adjusted difficulty levels and strong engagement . These sThe current study showed that striatal reward responsiveness predicts the subsequent experienced video gaming fun suggesting that individual differences in reward responsiveness might affect motivational engagement of video gaming, but this interpretation needs confirmation in future studies. Furthermore, this longitudinal study revealed that video game training may preserve reward responsiveness in the VS in a re-test. We believe that video games are able to keep striatal responses to reward flexible, a mechanism which might be extremely important to keep motivation high, and thus might be of critical value for many different applications, including cognitive training and therapeutic possibilities. Future research should therefore investigate whether video game training might have an effect on reward-based decision-making, which is an important ability in everyday life.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.