Studies have shown that following bariatric surgery, there is an almost immediate reversal of type 2 diabetes. However, there still remains questions as to why this occurs and what possible explanations there may be. This paper aims to focus on several studies that have found a reversal of diabetes in obese patients who have undergone bariatric surgery. Furthermore, it explores several possibilities for the reasons behind this reversal including the role of AMP-activated protein kinase, the incretins gastric inhibitory peptide and glucagon-like peptide-1, and also looks at genetics. Bariatric surgery and a description of certain mechanisms are first described for an understanding. Following is a literature review of published studies on bariatric surgery, the reversal of diabetes following the procedure, and roles of AMPK and incretins. Because of the possibility that reduced caloric intake may not be the major factor in the diabetic reversal, it is suggested that further research be done on obese and normal weight patients and observe the levels of the mentioned mechanisms and also various genes to see if they offer a more thorough explanation.

Ziel dieser Arbeit ist es, Ergebnisse der endovaskulären Rekonstruktion bei akut rupturierten, dissezierenden Aneurysmen der dominanten intrakraniellen Vertebralarterien mit hämodynamischen Implantaten (Flow-Diverter) zu untersuchen, einschließlich klinischer und verfahrenstechnischer Aspekte sowie klinischer Ergebnisse, um Machbarkeit, Sicherheit und Wirksamkeit dieses Ansatzes darzustellen. Zur Bearbeitung dieser sehr seltenen, jedoch klinisch relevanten Konstellation wurden zwischen 2010 und 2020 in vier neurovaskulären Zentren bzw. Fachabteilungen 31 Patienten im Alter von 30–78 Jahren (x̄ 55,5 Jahre) erfasst, die aufgrund eines Dissektionsaneurysmas der dominanten A. vertebralis eine Subarachnoidalblutung erlitten und bei denen dissezierende Aneurysmen einer dominanten A. vertebralis mit flußrichtenden Stents behandelt wurden. Beteiligte Kliniken waren das Universitätsklinikum Leipzig, das Katharinenhospital Stuttgart, das Berufsgenossenschaftliche Krankenhaus Bergmannstrost Halle/Saale und das Heinrich-Braun-Klinikum Zwickau. Von den 31 Patienten hatten 11 das dissezierende Aneurysma an der rechtsseitigen dominanten Vertebralarterie, während die restlichen Patienten das dissezierende Aneurysma an der linksseitigen dominanten Vertebralarterie hatten. Bei sechs Patienten betraf das dissezierende Aneurysma morphologisch die A. basilaris. In allen Fällen wurde eine Gefäßrekonstruktion mit unterschiedlichen flussumlenkenden Stents durchgeführt. Ein Fall erforderte eine zusätzliche Flüssigkeitsembolisation nach einer Verfahrensruptur, in drei Fällen war ein additives Coiling notwendig und in weiteren drei Fällen wurden unterschiedliche Flow Diverter Modelle miteinander und/oder mit Koronarstents kombiniert. Die Kriterien der klinischen Verlaufsbeurteilung erfolgten anhand der Glasgow Outcome Scale (GOS). Zur Einteilung des Schweregrades der Subarachnoidalblutung wurde anhand der Bildgebung die Fisher-Skala und anhand der Klinik die Klassifikation nach Hunt und Hess verwendet. Neun von 31 Patienten (29 %) erreichten nur ein ungünstiges Outcome (GOS 1–3). Fünf der sechs im Rahmen der SAB verstorbenen Patienten (GOS 1) zeigten bereits schwere Defizite vor der endovaskulären Behandlung (Grad III-V nach Hunt und Hess). Ein Patient mit GOS 2 erlitt ein apallisches Syndrom nach einer vorausgegangenen frühen erneuten Blutung innerhalb von 24 h nach der Behandlung. Zwei Patienten wiesen eine schwere Behinderung (GOS 3) auf und vier erlangten ihre Selbstständigkeit im Alltag zurück (GOS 4). Achtzehn Patienten zeigten eine vollständige Genesung (GOS 5). Zusammengefasst zeigt die Arbeit, dass die rekonstruktive Behandlung von rupturierten dissezierenden Aneurysmen der dominanten Vertebralarterie mit Flow- Diverter-Stents ein technisch sicherer und effektiver Ansatz in einer akuten Situation mit komplexem Lokalbefund ist, für deren interventionelle Behandlung bisher keine anderen wirksamen Optionen oder standardisierten Behandlungspfade definiert wurden. Die Schwere der Erkrankung spiegelt sich trotz technisch erfolgreicher endovaskulärer Behandlung dennoch in relativ hohen Morbiditäts- (23%) und Mortalitätsraten (19%) wider, die ohne ursächliche endovaskulären Behandlung allerdings in Mortalitätsraten von etwa 50 % gipfeln würden.:1. Einführung 1.1 Einleitung 3 1.2 Arterielle Dissektionen des vertebrobasilären Stromgebietes 1.2.1 Epidemiologie 5 1.2.2 Ätiologie 5 1.2.3 Anatomie 6 1.2.4 Pathophysiologie 10 1.2.5 Klinische Symptomatik 11 1.2.6 Diagnostik 12 1.2.7 Therapieoptionen und Einordnung der vorliegenden Arbeit 16 1.2.8 Klinische Ergebnisse und Prognose 21 1.3 Abkürzungsverzeichnis 23 1.4 Abbildungsverzeichnis 24 2. Publikationsmanuskript 25 Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage – A Retrospective Study From Four Neurovascular Centers 3. Zusammenfassung 35 4. Literaturverzeichnis 38 5. Darstellung des eigenen wissenschaftlichen Beitrages 46 6. Erklärung über die eigenständige Abfassung der Arbeit 47 7. Lebenslauf 48 8. Danksagung 51

Currently available VR-diversion solutions for vaccination lack key features for delivering an immersive and pleasurable experience. A tailor-made diversionary semi-interactive VR-experience software for vaccination procedures has been developed using mainly the game engine Unity and programmed in C#. The software aims to reduce or prevent anxiety, fear, and pain during these procedures. It is predominantly intended to be used by children as a tool for prevention. The narrative of the experience runs in parallel with the different steps and events of a vaccination procedure on the left arm. The interactions from the patient are only made using head gestures and no other controllers or movements of the body are used. The sequence can be initiated, restarted, and followed by a healthcare professional using a controller. The software is in a testable and applicable state but can be improved upon and polished in various areas. / Nuvarande VR-avledningslösningar för vaccination saknar viktiga funktioner för att leverera en immersiv och trevlig upplevelse. En skräddarsydd avledande semi-interaktiv VR-upplevelseprogramvara för vaccinationsprocedurer har utvecklats med huvudsakligen spelmotorn Unity och programmerats i C#. Programvaran syftar till att minska eller förebygga ångest, rädsla och smärta under dessa procedurer. Den är främst avsedd att användas av barn som ett förebyggande verktyg. Berättelsen i upplevelsen löper parallellt med de olika stegen och händelserna i en vaccinationsprocedur på vänster arm. Interaktionerna från patienten görs endast med hjälp av huvudgester och inga andra kontroller eller rörelser av kroppen används. Sekvensen kan initieras, startas om och följas av sjukvårdspersonal som använder en handkontroll. Programvaran är i ett testbart och tillämpligt tillstånd men kan förbättras och poleras inom olika områden.

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The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation. / Urban Bioethics

In October 2012, Hurricane Sandy caused massive disruption and destruction to the Mid-Atlantic region of the United States. The intensity of the storm forced the Port of New York and New Jersey to close, forcing cargo diversion to the Port of Norfolk in Virginia. Because of the Jones Act restriction on foreign vessels moving between U.S. ports, the restriction on short sea shipping was viewed as a barrier to recovery. Much of the critical infrastructure resilience and security literature focuses on the "hardening" of physical infrastructure, but not the relationship between law, policy, and critical infrastructure. Traditional views of transportation systems do not adequately address questions of governance and behaviors that contribute to resilience. In contrast, recent development of a System of Systems framework provides a conceptual framework to study the relationship of law and policy systems to the transportation systems they govern. Applying a System of Systems framework, this research analyzed the effect of relaxing the Jones Act on freight transportation networks experiencing a disruptive event. Using WebTRAGIS (Transportation Routing Analysis GIS), the results of the research demonstrate that relaxing the Jones Act had a marginal reduction on highway truck traffic and no change in rail traffic volume in the aftermath of a disruption. The research also analyzed the Jones Act waiver process and the barriers posed by the legal process involved in administration and review for Jones Act waivers. Recommendations on improving the waiver process include greater agency coordination and formal rulemaking to ensure certainty with the waiver process. This research is the first in studying the impact of the Jones Act on a multimodal freight transportation network. Likewise, the use of the System of Systems framework to conceptualize the law and a critical infrastructure system such as transportation provides future opportunities for studying different sets of laws and policies on infrastructure. This research externalizes law and policy systems from the transportation systems they govern. This can provide policymakers and planners with an opportunity to understand the impact of law and policy on the infrastructure systems they govern. / PHD

L'anévrisme intracrânien est la prédisposition mortelle la plus fréquente chez le sujet jeune. Sa compréhension demeure limitée alors que nous assistons au développement de nouveaux traitements endovasculaires permettant le traitement d'anévrismes de plus en plus complexes. L'essentiel des études sur le sujet repose sur des séries cliniques peu informatives, l'utilisation de méthodes de simulation numérique limitées et cible presque exclusivement les phénomènes mécaniques intrasacculaires sans tenir compte des conséquences de l'anévrisme sur l'artère porteuse. In vitro, l'utilisation d'anévrismes en silicone au sein d'un simulateur cardiovasculaire a permis d'objectiver un impact de l'anévrisme sur l'écoulement au sein du vaisseau porteur caractérisé par une diminution de sa résistance. In vivo, cet effet a été objectivé et mesuré en IRM de flux par l'analyse des courbes de débit volumétrique. Le flux sanguin en aval des anévrismes était caractérisé par une démodulation systolo-diastolique avec diminution des index de résistance et de pulsatilité. Cet effet était fortement corrélé au volume de l'anévrisme. Les stents flow diverters permettaient une « reconstruction hémodynamique » mesurable du vaisseau porteur en restaurant un flux normo-modulé et des index de pulsatilité et de résistance dans les limites de la normale. Une méthode originale pour la segmentation de l'artère carotide interne en IRM en contraste de phase 2D a été proposée. Elle se base sur l'application de la Transformée de Fourier sur les images de phase et la prise en compte de la cohérence temporelle des vitesses au sein du voxel. La méthode a été caractérisée et comparée à deux méthodes de référence / Intracranial aneurysms are the most common lethal predisposition amongst young adults. Its understanding remains limited to date while the development of new innovative endovascular treatments are increasingly available and allow for the treatment of more and more complex aneurysms with a non negligeable rate of complications. Most of the previous studies on intracranial aneurysms are based on low informative clinical series and the use of limited numerical simulation methods. They almost exclusively target the intrasaccular mechanical phenomena irrespective of the changes in the parent vessel induced by the aneurysm. In vitro, the use of silicone aneurysms embedded in a cardiovascular simulator showed an impact of the aneurysm on the the parent vessel flow conditions characterized by a decrease of its resistance. In vivo, flow MRI allowed to quantify this effect by analyzing the volumetric flow rate curves. Downstream to the aneurysm, the blood flow was dampened and presents a systolic diastolic demodulation with a collapse of resistive and pulsatility indexes. This effect was strongly correlated to the aneurysm volume. The flow diverter stents allowed for a measurable « hemodynamic reconstruction » of the parent vessel by restoring a normo modulated flow, and normal resistive and pulsatility indexes. An original method for the segmentation of internal carotid artery in 2D phase contrast MRI was proposed. It is based on the application of the Fourier Transform on the phase images and by taking into account the temporal coherence of velocities within the voxel. The method was characterized and compared to two reference methods

Chemical dependency in the health profession is a growing concern. With easy access to controlled substances, many nurses divert prescription drugs and even work while under the influence. Nurses who are under the influence and working with patients are an obvious public hazard. Many states in the USA have non-punitive programs to offer recovery to nurses with chemical dependency and return them to work. In California this program is named the Diversion Program. Part of the requirements of successful completion of the Diversion Program is to attend weekly meetings called support groups. These support groups are facilitated by other nurses experienced in the field of chemical dependency. This study explored the experiences of nurse facilitators of support groups for nurses with chemical dependency in the California, USA, Diversion Program. Data were collected through twelve individual interviews selected through purposeful, non-probability convenience sampling. A phenomenological research design was used that was descriptive, explorative, and contextual. The data analysis revealed four major themes: (1) experience of communication within the Diversion Program; (2) experience of the structure of the Diversion Program; (3) experience of their role within the Diversion Program; and (4) experience of facilitation of support groups. The study revealed that even though many of the nurse facilitators‟ experiences were positive with respect to the support groups they expressed concern about the communication patterns within the Diversion Program. To offer support for the nurse facilitators, guidelines and a conceptual framework were created to enhance their experience and mitigate their feelings of marginalization from the Diversion Program. / Health Studies / D.Litt. et Phil. (Health Studies)

The Barrage informal settlement (BIS) is a peri-urban community of about 300 people resident on private land close to the banks of the Vaal River in Gauteng South Africa. The study focuses on the living and sanitation conditions in which people find themselves. Measured against the Millennium Development Goals (MDGs) BIS and its residents clearly are far from meeting MDG 7 target 7 C. For the purposes of this study the researcher investigated ecological sanitation (EcoSan) as an alternative solution for the current local sanitation conundrum. Residents either use the veld or a dysfunctional pit system. The data used for the project was generated both in a qualitative and quantitative mode. Semi-structured interviews were randomly conducted. Participants were requested and subsequently assisted in completing a questionnaire. There were also several focus group discussions for gathering relevant data. The researcher tried to form an impression of the perceptions of community members in terms on the type of sanitation system they wished to use. Community members actively engaged in strategies aimed to find out how they perceive sanitation, potable water supply and matters of hygiene. The findings revealed dissatisfaction regarding to current conditions in BIS. Residents are uncertain because the land on which they reside on does not belong to them. This, in turn, creates uncertainty and feelings of insecurity, about the relevance of a potential water-based sanitation system. At the same time members of the community indicated they had no interest in a dry toilet system. Neither are they keen on the use of community ablution blocks (CABs) as alternative. Residents showed no willingness and are also not prepared to pay for sanitation because they cannot afford it. The dilemma is that residents are at the mercy of Emfuleni Local Municipality (ELM) and the private owners of the land on which they reside. Where do we find the solution to all of the issues? Participatory deliberation strategies were used to determine which system of sanitation local residents preferred. They clearly came out in favour of the Water Bank concept as a feasible sanitation system option. However, as a result of the unfulfilled promises of Emfuleni Local Municipality (ELM) and landowners the community remains in a state of uncertainty about the permanence of the BIS.

The Barrage informal settlement (BIS) is a peri-urban community of about 300 people resident on private land close to the banks of the Vaal River in Gauteng South Africa. The study focuses on the living and sanitation conditions in which people find themselves. Measured against the Millennium Development Goals (MDGs) BIS and its residents clearly are far from meeting MDG 7 target 7 C. For the purposes of this study the researcher investigated ecological sanitation (EcoSan) as an alternative solution for the current local sanitation conundrum. Residents either use the veld or a dysfunctional pit system. The data used for the project was generated both in a qualitative and quantitative mode. Semi-structured interviews were randomly conducted. Participants were requested and subsequently assisted in completing a questionnaire. There were also several focus group discussions for gathering relevant data. The researcher tried to form an impression of the perceptions of community members in terms on the type of sanitation system they wished to use. Community members actively engaged in strategies aimed to find out how they perceive sanitation, potable water supply and matters of hygiene. The findings revealed dissatisfaction regarding to current conditions in BIS. Residents are uncertain because the land on which they reside on does not belong to them. This, in turn, creates uncertainty and feelings of insecurity, about the relevance of a potential water-based sanitation system. At the same time members of the community indicated they had no interest in a dry toilet system. Neither are they keen on the use of community ablution blocks (CABs) as alternative. Residents showed no willingness and are also not prepared to pay for sanitation because they cannot afford it. The dilemma is that residents are at the mercy of Emfuleni Local Municipality (ELM) and the private owners of the land on which they reside. Where do we find the solution to all of the issues? Participatory deliberation strategies were used to determine which system of sanitation local residents preferred. They clearly came out in favour of the Water Bank concept as a feasible sanitation system option. However, as a result of the unfulfilled promises of Emfuleni Local Municipality (ELM) and landowners the community remains in a state of uncertainty about the permanence of the BIS.