The Milan score: A novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease.

OBJECTIVE: A definitive diagnosis of gastroesophageal reflux disease (GERD) depends on endoscopic and/or pH-study criteria. However, high resolution manometry (HRM) can identify factors predicting GERD, such as ineffective esophageal motility (IEM), esophago-gastric junction contractile integral (EGJ-CI), evaluating esophagogastric junction (EGJ) type and straight leg raise (SLR) maneuver response. We aimed to build and externally validate a manometric score (Milan Score) to stratify the risk and severity of the disease in patients undergoing HRM for suspected GERD. METHODS: A population of 295 consecutive patients undergoing HRM and pH-study for persistent typical or atypical GERD symptoms was prospectively enrolled to build a model and a nomogram that provides a risk score for AET > 6%. Collected HRM data included IEM, EGJ-CI, EGJ type and SLR. A supplemental cohort of patients undergoing HRM and pH-study was also prospectively enrolled in 13 high-volume esophageal function laboratories across the world in order to validate the model. Discrimination and calibration were used to assess model's accuracy. Gastroesophageal reflux disease was defined as acid exposure time >6%. RESULTS: Out of the analyzed variables, SLR response and EGJ subtype 3 had the highest impact on the score (odd ratio 18.20 and 3.87, respectively). The external validation cohort consisted of 233 patients. In the validation model, the corrected Harrel c-index was 0.90. The model-fitting optimism adjusted calibration slope was 0.93 and the integrated calibration index was 0.07, indicating good calibration. CONCLUSIONS: A novel HRM score for GERD diagnosis has been created and validated. The MS might be a useful screening tool to stratify the risk and the severity of GERD, allowing a more comprehensive pathophysiologic assessment of the anti-reflux barrier. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT05851482).

Dangerous passage: the utility and accuracy of modern chest computed tomography in penetrating thoracic injuries with potential transmediastinal trajectory.

AIM: The aim of this study is to evaluate utility and reliability of chest CT as a standalone screening modality for stable patients with thoracic GSWs and potential transmediastinal trajectories. METHODS: All patients with thoracic GSWs over a 5-year period were identified. Unstable patients requiring immediate surgery were excluded and the remaining underwent chest CT with intravenous contrast. Sensitivity and specificity for clinically significant injuries were tested against an aggregate gold standard of discharge diagnosis including imaging, operative and clinical findings. RESULTS: A total of 216 patients met inclusion criteria and underwent chest CT. After imaging, 65 (30.1%) had indication for immediate surgery, of which 10 (4.6%) underwent a thoracic procedure for chest injuries while 151 (69.9%) were selected for nonoperative management (NOM). 11 (5.1%) required a delayed thoracic operation, none due to injuries missed on CT. The remaining 140 (64.8%) underwent successful NOM. Up to 195 (90.3%) patients had successful NOM of thoracic injuries. Only 9.2% required additional imaging, all negative. CT identified a cardiac injury in one case and a vascular injury in two cases, all confirmed by surgery, while one thoracic IVC injury missed on CT was found intraoperatively. 2 patients had CT suspicious for esophageal injury, ruled out by following investigations. There was one death in the total cohort, none in the NOM group. CONCLUSIONS: Modern high-quality CT provides highly accurate and reliable screening modality for penetrating chest and mediastinal injuries and can be used as a standalone study in most patients or to guide further tests. Chest CT facilitated successful NOM.

Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma.

INTRODUCTION: Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults. METHODS: Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management. RESULTS: Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation. CONCLUSION: Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.

Epidemiology and outcomes of traumatic vascular injury repair by trauma surgeons and vascular surgeons in a collaborative model.

BACKGROUND: Management roles for peripheral vascular injuries (PVI) are a source of ongoing debate given the concern for the loss of vascular skills among general surgeons and trauma surgeons (TS). We sought to analyze outcomes of PVI managed by TSs or vascular surgeons (VSs). METHODS: This is a retrospective study of a single, Level I trauma center. Trauma patients with PVI who underwent repair from 2010 to 2021 were included. Patients were separated into groups by the surgical specialty (TS or VS) undertaking the first intervention of the injured vessel. RESULTS: A total of 194 patients were included, with 101 (52%) PVI managed by TS and 93 (48%) by VS. The TS group had more penetrating injuries (84% vs. 63%, p < 0.01), were more often hypotensive (17% vs. 6%, p = 0.01), and had a higher median Injury Severity Score (10 vs. 9, p < 0.001). Time from arrival to operating room was lower in the TS group (77 vs. 257 minutes, p < 0.01), with no difference in rates of preoperative imaging. The TS group performed damage-control surgery (DCS) more frequently (21% vs. 1.1%, p < 0.01). There was no difference in reintervention rates between the two groups after excluding patients that required reintervention for definitive repair after DCS (13% vs. 9%, p = 0.34). Mortality was 8% in the TS group and 1% in the VS group ( p = 0.02) with no deaths related to the PVI repair in either group. There was no difference in PVI repair complication rates between the two groups (18% vs. 13%; p = 0.36). CONCLUSION: In our collaborative model at a high-volume trauma center, a wide variety of PVI are surgically managed by TS with VS. immediately available for consultation or for definitive repair of more complex vascular injuries. Trauma surgeons performed more DCS on higher acuity patients. No difference in vascular-related complications was detected between groups. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Asymptomatic Covid-19 Trauma Patients Have Worse Outcomes and Resource Utilization: A Matched Cohort Study.

OBJECTIVE: To evaluate the impact of COVID-19 positivity on outcomes and resource utilization in the trauma population. INTRODUCTION: COVID-19 infection worsens outcomes of trauma patients, but it is not known if asymptomatic COVID-19 trauma patients have different outcomes from COVID-19-negative patients. METHODS: All trauma patients admitted to an urban level 1 trauma center between March 2020 and October 2021 were collected and reviewed for COVID-19 status. COVID-19-positive patients with symptoms or initial chest radiographs consistent with infections were excluded. Propensity score model 1:3 matched asymptomatic COVID-19-positive to COVID-19-negative trauma patients for their age, body mass index, MOA, injury severity score, SBP<90, GCS<9, and comorbidities. Outcomes included mortality, complications, and resource utilization. RESULTS: A total of 185 asymptomatic COVID-19-positive patients were matched with 554 COVID-19-negative patients. Asymptomatic COVID-19 -positive patients had higher rates of myocardial infarction and cardiac arrest (3.2% vs. 0.9%, P =0.023), higher ventilator days (3.33 vs. 1.49 days, P <0.001), ICU-length of stay [LOS (4.92 vs. 3.41 d, P =0.034)], overall LOS (11.41 vs. 7.24 d, P <0.001), and hospital charges ($ 176.505.80 vs. 107.591.93, P =0.002). CONCLUSION: Asymptomatic COVID-19 trauma patients have significantly higher rates of cardiac events, longer LOS, and higher hospital charges when compared with similar trauma patients who are COVID-19-negative.

Prevalence of cesarean sections in swiss Bernese Mountain Dogs (2001-2020) and identification of risk factors.

BACKGROUND: Dystocia is an important limiting factor in animal breeding due to its cost, stress for the mother and risk of death for the neonates. Assessment of incidence and characteristics of dystocia and the inherent risk of Cesarean section are of major importance. The aim of the present study was to evaluate the reproductive performance of Bernese Mountain Dogs in Switzerland, with a particular focus on the prevalence of Cesarean sections due to dystocia, and identification of possible risk factors. RESULTS: The investigated population included 401 bitches, 207 sires, and 1127 litters. Litter size was significantly influenced by age and parity of the dam. Incidence of Cesarean section was 30.4%, with 2.0% of procedures being elective. History of previous Cesarean section, age of the dam, and a small litter size significantly influenced the risk for Cesarean section. The stillbirth rate was 12.0%, and the number of stillborn pups was significantly higher for litters delivered by Cesarean sections after birth of the first pup. The inbreeding coefficient had a low to non-significant impact on all reproductive parameters (e.g., litter size, number of stillborn pups). CONCLUSION: The sample of Bernese Mountain Dogs of our study had an increased prevalence of Cesarean sections compared to the literature, and advanced age of the dam, litter size and prior Cesarean sections in the dam's reproductive history was identified as significantly influencing factors. In order to improve pups' survival rate, elective Cesarean section may be indicated in bitches that have had a previous Cesarean-section/s, are of advanced age, and/or have a small litter.

wGrapeUNIPD-DL: An open dataset for white grape bunch detection.

National and international Vitis variety catalogues can be used as image datasets for computer vision in viticulture. These databases archive ampelographic features and phenology of several grape varieties and plant structures images (e.g. leaf, bunch, shoots). Although these archives represent a potential database for computer vision in viticulture, plant structure images are acquired singularly and mostly not directly in the vineyard. Localization computer vision models would take advantage of multiple objects in the same image, allowing more efficient training. The present images and labels dataset was designed to overcome such limitations and provide suitable images for multiple cluster identification in white grape varieties. A group of 373 images were acquired from later view in vertical shoot position vineyards in six different Italian locations at different phenological stages. Images were then labelled in YOLO labelling format. The dataset was made available both in terms of images and labels. The real number of bunches counted in the field, and the number of bunches visible in the image (not covered by other vine structures) was recorded for a group of images in this dataset.

Radiative transfer model inversion using high-resolution hyperspectral airborne imagery - Retrieving maize LAI to access biomass and grain yield.

Mapping crop within-field yield variability provide an essential piece of information for precision agriculture applications. Leaf Area Index (LAI) is an important parameter that describes maize growth, vegetation structure, light absorption and subsequently maize biomass and grain yield (GY). The main goal for this study was to estimate maize biomass and GY through LAI retrieved from hyperspectral aerial images using a PROSAIL model inversion and compare its performance with biomass and GY estimations through simple vegetation index approaches. This study was conducted in two separate maize fields of 12 and 20 ha located in north-west Mexico. Both fields were cultivated with the same hybrid. One field was irrigated by a linear pivot and the other by a furrow irrigation system. Ground LAI data were collected at different crop growth stages followed by maize biomass and GY at the harvesting time. Through a weekly/biweekly airborne flight campaign, a total of 19 mosaics were acquired between both fields with a micro-hyperspectral Vis-NIR imaging sensor ranging from 400 to 850 nanometres (nm) at different crop growth stages. The PROSAIL model was calibrated and validated for retrieving maize LAI by simulating maize canopy spectral reflectance based on crop-specific parameters. The model was used to retrieve LAI from both fields and to subsequently estimate maize biomass and GY. Additionally, different vegetation indices were calculated from the aerial images to also estimate maize yield and compare the indices with PROSAIL based estimations. The PROSAIL validation to retrieve LAI from hyperspectral imagery showed a R2 value of 0.5 against ground LAI with RMSE of 0.8 m2/m2. Maize biomass and GY estimation based on NDRE showed the highest accuracies, followed by retrieved LAI, GNDVI and NDVI with R2 value of 0.81, 0.73, 0.73 and 0.65 for biomass, and 0.83, 0.69, 0.73 and 0.62 for GY estimation, respectively. Furthermore, the late vegetative growth stage at V16 was found to be the best stage for maize yield prediction for all studied indices.

Measuring Comfort Behaviours in Laying Hens Using Deep-Learning Tools.

Image analysis using machine learning (ML) algorithms could provide a measure of animal welfare by measuring comfort behaviours and undesired behaviours. Using a PLF technique based on images, the present study aimed to test a machine learning tool for measuring the number of hens on the ground and identifying the number of dust-bathing hens in an experimental aviary. In addition, two YOLO (You Only Look Once) models were compared. YOLOv4-tiny needed about 4.26 h to train for 6000 epochs, compared to about 23.2 h for the full models of YOLOv4. In validation, the performance of the two models in terms of precision, recall, harmonic mean of precision and recall, and mean average precision (mAP) did not differ, while the value of frame per second was lower in YOLOv4 compared to the tiny version (31.35 vs. 208.5). The mAP stands at about 94% for the classification of hens on the floor, while the classification of dust-bathing hens was poor (28.2% in the YOLOv4-tiny compared to 31.6% in YOLOv4). In conclusion, ML successfully identified laying hens on the floor, whereas other PLF tools must be tested for the classification of dust-bathing hens.

Reference high-resolution manometry values after magnetic sphincter augmentation.

BACKGROUND: Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high-resolution manometry (HRM) values after MSA implantation. METHODS: High-resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed. KEY RESULTS: Eighty-four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ-A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone. CONCLUSION & INFERENCES: This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes.

Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis.

Background/Aims: According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes. Methods: A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated. Results: Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position (P < 0.001). Conclusions: Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed.

A sample of Italian vineyards: Landscape and management parameters dataset.

Agricultural land use plays a critical role in land planning sustainability. Employing a GIS-based decision-making protocol based on spatial and management data represents an appropriate tool for land planning. The Italian vineyards database presented here describes several spatial and management features of 3686 sample vineyards distributed throughout Italy. The dataset is presented as a centroid shapefile with the attribute table. The features were assessed with a GIS-based geospatial analysis. Parameters such as training system and shape of the vineyard block were attributed through visual assessment of Google Earth images. Row spacing, length-width ratio and headland size were determined using QGIS measuring tools. The mean and maximum slope was derived using a 20 m spatial resolution Digital Elevation Model (DEM). This database may help to establish planting criteria of new vineyards which comply with rational and sustainable requirements. Moreover, the dataset could be combined with other agricultural land use data for further analysis of land management. Furthermore, the database could be implemented to support global-scale vineyard management.

High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease.

BACKGROUND: Magnetic sphincter augmentation with the Linx® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables. METHODS: The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study. KEY RESULTS: Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P < .001). Distal esophageal amplitude (P = .004), mean distal contractile integral (DCI) (P < .001), post multiple repeated swallows DCI (P = .001), and the percent of normal peristalsis increased (P = .040). All patients were relieved of reflux symptoms. Ineffective esophageal motility reversed to normal in 36% of patients after surgery. The only factor significantly associated with postoperative dysphagia was preoperative dysphagia (P = .006). Postoperatively, a significant correlation between IRP and DCI (r = 0.361 and P = .019) and between IBP and DCI (r = 0.443 and P = .003) was found. CONCLUSIONS AND INFERENCES: The Linx procedure had a remarkable effect on esophageal motility in the short-term follow-up. It appears that the overall postoperative increase of IRP and IBP may justify the higher DCI values. Preoperative dysphagia was the only factor associated with postoperative dysphagia.

Minimally invasive esophagectomy for Barrett's adenocarcinoma.

Minimally invasive esophagectomy has become the preferred approach for invasive Barrett's adenocarcinoma because it can speed recovery and enhance patient's quality of life. Multiple minimally invasive surgical techniques have been described during the last two decades. Preoperative staging, anatomy and physiological patient's status, comorbidity, and experience of the surgical team should drive the choice of the surgical approach. The trans-thoracic Ivor Lewis esophagectomy, either hybrid or totally minimal invasive, remains the preferred approach in these patients. Lymph node yield and short-term clinical outcomes have proven similar to open surgery, while quality of life appears improved. To establish a minimally invasive esophagectomy program, a steep learning curve and a multidisciplinary approach are required in order to provide optimal staging, personalized therapy, and adequate perioperative care. The role of minimally invasive surgery in the treatment of invasive Barrett's adenocarcinoma will continue to expand in synergy with enhanced recovery after surgery pathways.

Respiratory Symptoms and Complications of Zenker Diverticulum: Effect of Trans-Oral Septum Stapling.

BACKGROUND: Zenker diverticulum is a rare condition commonly associated with dysphagia and respiratory symptoms/complications, which are alarming especially in the elderly population. Aim of this study was to investigate the prevalence of respiratory symptoms/complications and the effects of minimally invasive trans-oral surgery in these patients. METHODS: Consecutive adult patients who underwent trans-oral septum stapling for Zenker diverticulum were included in a retrospective, observational cohort study. Pre- and postoperative symptoms, including chronic cough and aspiration pneumonia, were evaluated using a dedicated foregut questionnaire and were recorded on a prospectively maintained database. The operation was performed under general anesthesia. A barium swallow study and an upper gastrointestinal endoscopy were performed 6 months after the operation, and the foregut questionnaire was administered yearly. RESULTS: A total of 139 patients were finally included in the study. The median age was 72 years. In 62 (44.6%, CI 36.2-53.3) patients, there was a history of chronic cough and/or aspiration pneumonia. Chronic cough was associated with pneumonia (p < 0.001), while pneumonia was associated with severe regurgitation (p < 0.042) and weight loss (p = 0.001). The overall postoperative morbidity rate was 2.2% and there was no mortality. The median postoperative hospital stay was 2 days (range 0-22). The median follow-up was 38 months (range 2-105). At 3 years, a statistically significant reduction in the rate of chronic cough (36.8 vs. 7.9%, p < 0.001), recurrent episodes of pneumonia (6.6 vs. 0.0%, p = 0.031), dysphagia (78.9 vs. 6.6%, p < 0.001), and regurgitation (67.1 vs. 6.6%, p < 0.001) was recorded. The probability of remaining symptom-free at 90 months of follow-up was 0.818 (CI: 0.745-0.899). CONCLUSIONS: Trans-oral septum stapling is safe and can effectively reduce the burden of respiratory symptoms and complications associated with Zenker diverticulum.

Short-Term Outcomes of Minimally Invasive Esophagectomy for Carcinoma In Patients with Liver Cirrhosis.

BACKGROUND: Open esophagectomy is a high-risk procedure in patients with liver cirrhosis. With the advent of minimally invasive surgical techniques, the overall morbidity and mortality rates of esophagectomy have decreased. The aim of this study was to describe short-term outcomes of minimally invasive esophagectomy in patients with proven liver cirrhosis. METHODS: Retrospective observational cohort study. Demographics, preoperative clinical characteristics, and outcomes of patients undergoing minimally invasive esophagectomy for carcinoma were analyzed. Patients with concomitant liver cirrhosis were compared to patients without liver cirrhosis undergoing similar surgical procedures. In addition, variables possibly associated with postoperative morbidity and mortality in patients with cirrhosis were investigated. RESULTS: Out of 443 patients undergoing minimally invasive esophagectomy, 18 (4.1%) had concomitant liver cirrhosis. Demographics and preoperative clinical variables were similar in the 2 patient groups. While the overall morbidity rate was similar, the 90-day mortality rate was significantly higher in patients with liver cirrhosis (P = .023). There was a significantly higher rate of sepsis and anastomotic, respiratory, and hemorrhagic complications in patients with liver cirrhosis who died in the postoperative period. CONCLUSIONS: Minimally invasive esophagectomy is feasible in patients with liver cirrhosis. Future strategies should focus on total minimally invasive procedures and early recognition of surgical complications.