Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Development of the Circle of Willis Score (COWS) to help guide decision making during acute tandem occlusion treatment: Preliminary analysis.

BACKGROUND: Acute tandem occlusions (TOs) are challenging to treat. Although acute carotid stenting of the proximal lesion is well tolerated, there are certain situations when the practitioner may be wary of acute stenting (bleeding concerns). OBJECTIVE: The purpose of this study was to retrospectively study patients with tandem occlusions who had re-occlusion of the extracranial ICA and develop a Circle of Willis Score (COWS) to help predict which patients could forego acute stenting. METHODS: This is a retrospective review of TO patients with a persistent proximal occlusion following intervention (either expected or unexpected). Pre intervention CTA and intraoperative DSA were reviewed, and each patient was assigned a score 2 (complete COW), 1a (patent A1-Acomm-A1), 1p (patent Pcomm), or 0 (incomplete COW). Findings from the DSA took precedence over the CTA. Two cohorts were created, the complete COW cohort (COWS 2) versus the incomplete COW cohort (COWS 1a,1p, or 0). Angiographic outcomes were assessed using the mTICI score (2b-3) and clinical outcomes were assessed using discharge mRS (good outcome mRS 0-3). RESULTS: Of 68 TO cases, 12 had persistent proximal occlusions. There were 5/12 (42 %) patients in the complete COW cohort, and 7/12 (58 %) in the incomplete COW cohort (5/12 with scores of 1a/1p and 2/12 with a score of 0). In the complete COW cohort, there were 2 ICA-ICA and 3 ICA-MCA occlusions. In the incomplete COW cohort, there was one ICA-ICA occlusion and 6 ICA-MCA occlusions. LKW-puncture was shorter in the complete COW cohort (208 min vs. 464 min, p = 0.16). Successful reperfusion was higher in the complete COW cohort (100 % vs. 71 %). There was a trend toward better clinical outcomes in the complete COW cohort (80 % vs 29 %, p = 0.079). CONCLUSION: The COWS is a simple score that may help predict a successful clinical outcome without proximal revascularization when concerned about performing an acute carotid stent during TO treatment. Evaluation in larger TO cohort is warranted.

Promoter insertion leads to polyembryony in mango - a case of convergent evolution with citrus.

Sexual reproduction in plants is the main pathway for creating new genetic combinations in modern agriculture. In heterozygous plants, after the identification of a plant with desired traits, vegetative propagation (cloning) is the primary path to create genetically uniform plants. Another natural plant mechanism that creates genetically uniform plants (clones) is apomixis. In fruit crops like citrus and mango, sporophytic apomixis results in polyembryony, where seeds contain multiple embryos, one of which is sexually originated and the others are vegetative clones of the parent mother tree. Utilizing the mango genome and genetic analysis of a diverse germplasm collection, we identified MiRWP as the gene that causes polyembryony in mango. There is a strong correlation between a specific insertion in the gene's promoter region and altered expression in flowers and developing fruitlets, inducing multiple embryos. The MiRWP gene is an ortholog of CitRWP that causes polyembryony in citrus. Based on the data, we speculate that promoter insertion events, which occurred independently in citrus and mango, induced nucellar embryogenesis. The results suggest convergent evolution of polyembryony in the two species. Further work is required to demonstrate the utility of these genes (mango and citrus) in other biological systems as a tool for the clonal production of other crops.

Freudian robots: Artificial intelligence and psychodynamics.

OBJECTIVE: Artificial intelligence (AI) is rapidly developing, particularly human-interacting and affective AI systems. Psychodynamic concepts important to human development should be considered in the development of AI systems. CONCLUSION: The development of safe and ethical affective artificial intelligence that remains meaningful and flexible should incorporate psychodynamic concepts. Mental health professionals such as psychiatrists and psychotherapists should be involved in the development of AI to provide expert knowledge in the area of psychodynamics.

Impact of Unplanned Intra-Operative Conversions on Outcomes in Minimally Invasive Pancreatoduodenectomy.

BACKGROUND: Minimally-invasive pancreatoduodenectomy (MIPD) is fraught with the risk of complication-related deaths (LEOPARD-2), a significant volume-outcome relationship and a long learning curve. With rates of conversion for MIPD approaching 40%, the impact of these on overall patient outcomes, especially, when unplanned, are yet to be fully elucidated. This study aimed to compare peri-operative outcomes of (unplanned) converted MIPD against both successfully completed MIPD and upfront open PD. METHODS: A systematic review of major reference databases was undertaken. The primary outcome of interest was 30-day mortality. Newcastle-Ottawa scale was used to judge the quality of the studies. Meta-analysis was performed using pooled estimates, derived using random effects model. RESULTS: Six studies involving 20,267 patients were included in the review. Pooled analysis demonstrated (unplanned) converted MIPD were associated with an increased 30-day (RR 2.83, CI 1.62- 4.93, p = 0.0002, I2 = 0%) and 90-day (RR 1.81, CI 1.16- 2.82, p = 0.009, I2 = 28%) mortality and overall morbidity (RR 1.41, CI 1.09; 1.82, p = 0.0087, I2 = 82%) compared to successfully completed MIPD. Patients undergoing (unplanned) converted MIPD experienced significantly higher 30-day mortality (RR 3.97, CI 2.07; 7.65, p < 0.0001, I2 = 0%), pancreatic fistula (RR 1.65, CI 1.22- 2.23, p = 0.001, I2 = 0%) and re-exploration rates (RR 1.96, CI 1.17- 3.28, p = 0.01, I2 = 37%) compared upfront open PD. CONCLUSIONS: Patient outcomes are significantly compromised following unplanned intraoperative conversions of MIPD when compared to successfully completed MIPD and upfront open PD. These findings stress the need for objective evidence-based guidelines for patient selection for MIPD.

Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry.

BACKGROUND: Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE: To investigate factors that predict MTF. METHODS: This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF (

Delayed appearance of basilar trunk small atypical aneurysms in nontraumatic, initially angiogram-negative subarachnoid hemorrhage: A report of three patients.

BACKGROUND: Repeat angiography will identify vascular pathology in approximately 10% of cases following angiogram-negative subarachnoid hemorrhage (anSAH), but small atypical aneurysms of the basilar artery are very uncommon. OBJECTIVE: To report a case series of delayed appearance of nontraumatic basilar artery small atypical aneurysms. METHODS: IRB approval was obtained for this retrospective case series and patient consent was waived. RESULTS: Herein we report three cases of spontaneous anSAH, all of whom had a negative digital subtraction angiogram (DSA) on admission and all of whom had appearance of a small atypical aneurysms of the upper basilar trunk/apex on follow-up imaging (two during the initial admission and one in a delayed fashion). All three patients were ultimately treated with flow diversion (although one patient underwent attempted coiling that was abandoned due to inability to catheterize the aneurysm). CONCLUSION: This report highlights the importance of a repeat DSA in cases of anSAH as well as the importance of scrutinizing the basilar trunk for these very small atypical aneurysms that may go unnoticed.

Technical and clinical success after venous sinus stenting for treatment of idiopathic intracranial hypertension using a novel guide catheter for access: Case series and initial multi-center experience.

INTRODUCTION: Venous sinus stenting is a well established alternative to cerebrospinal fluid diversion for the treatment of idiopathic intracranial hypertension (IIH) with associated venous sinus stenosis. During this procedure, distal guide catheter placement within the venous sinuses may be desirable to facilitate stent delivery. We report our initial experience using the TracStar LDP™ (Imperative Care, Campbell, USA, 0.088-inch inner diameter) as the guide catheter for intracranial access during venous sinus stenting. METHODS: A multi-institutional retrospective chart review of a prospectively maintained IRB-approved database was performed. Consecutive patients who underwent venous sinus stenting from 1/1/2020-9/6/2021 for IIH were included. Patient characteristics, procedural details, TracStar distal reach, outcomes, and complications were collected and analyzed. RESULTS: Fifty-eight patients were included. The mean age was 33.8 years and 93.1% of patients were female. Visual changes prompted evaluation in 86.2% of patients. Stent placement was successful in all patients. The TracStar LDP catheter was advanced to the location of stent placement in 97.9% of cases in which it was attempted. The large 0.088-inch inner diameter lumen enabled compatibility with all desired stent sizes ranging from six to 10 millimeters. Gradient pressure across transverse sinus stenosis dropped from an average of 19.5 mmHg pre-procedure to 1.7 mmHg post-stent placement (p < 0.001). Clinical improvement was achieved in 87.9% (51/58) of patients. There were no catheter-related complications. CONCLUSION: The TracStar LDP is a safe and effective access platform for reaching treatment locations in patients who present with idiopathic intracranial hypertension and who are candidates for venous sinus stent placement.

Wide-Neck and Bifurcation Aneurysms: Balancing Open and Endovascular Therapies.

Wide-neck aneurysms (WNA) often require advanced open surgical and endovascular techniques to achieve adequate aneurysm occlusion. Microsurgical treatment often requires advanced clip configurations. Occasionally, more complex open surgical techniques are required. Advancements in endovascular therapies (EVT) and devices have expanded endovascular treatment options for WNAs and have improved aneurysm occlusion rates compared with primary coiling. Certain EVT require dual antiplatelet therapy, limiting their use in the ruptured setting. Evidence suggests that microsurgical treatment should remain a consideration for treatment of ruptured WNAs, but perhaps with novel endovascular techniques and devices, EVT should be first-line treatment in the unruptured setting.

Nanophotonic control of thermal emission under extreme temperatures in air.

Nanophotonic materials offer spectral and directional control over thermal emission, but in high-temperature oxidizing environments, their stability remains low. This limits their applications in technologies such as solid-state energy conversion and thermal barrier coatings. Here we show an epitaxial heterostructure of perovskite BaZr0.5Hf0.5O3 (BZHO) and rocksalt MgO that is stable up to 1,100 °C in air. The heterostructure exhibits coherent atomic registry and clearly separated refractive-index-mismatched layers after prolonged exposure to this extreme environment. The immiscibility of the two materials is corroborated by the high formation energy of substitutional defects from density functional theory calculations. The epitaxy of immiscible refractory oxides is, therefore, an effective method to avoid prevalent thermal instabilities in nanophotonic materials, such as grain-growth degradation, interlayer mixing and oxidation. As a functional example, a BZHO/MgO photonic crystal is implemented as a filter to suppress long-wavelength thermal emission from the leading bulk selective emitter and effectively raise its cutoff energy by 20%, which can produce a corresponding gain in the efficiency of mobile thermophotovoltaic systems. Beyond BZHO/MgO, computational screening shows that hundreds of potential cubic oxide pairs fit the design principles of immiscible refractory photonics. Extending the concept to other material systems could enable further breakthroughs in a wide range of photonic and energy conversion applications.

The majority of ruptured aneurysms are small with low rupture risk scores.

BACKGROUND: Understanding the rupture risk of unruptured intracranial aneurysms has important clinical implications given the morbidity and mortality associated with subarachnoid hemorrhage (SAH). The ISUIA, UCAS, and PHASES studies provide rupture risk calculations. OBJECTIVE: We apply the risk calculations to a series ruptured intracranial aneurysms to assess the rupture risk for each aneurysm (had they been discovered in the unruptured state). METHODS: This is a retrospective study of 246 patients with SAH from a ruptured saccular aneurysm. The ISUIA, UCAS, and PHASES calculators were applied to each patient/aneurysm to demonstrate a theoretical annual risk of rupture dichotomized by aneurysm location. RESULTS: The average diameter of the aneurysms was 5.5 ± 3.1 mm. Three quarters (75%) of the aneurysms measured <7 mm and 48.8% were <5 mm. The anterior communicating artery (Acomm) was the most common location of rupture (24.7%). Posterior communicating artery aneurysms (Pcomm) were the third most common at 16.2%. The average ISUIA 1-year rupture risk was 0.46 ± 0.008%. The average UCAS 1-year rupture risk was 0.93% ± 0.01. The annualPHASESrupture risk was0.32 ± 0.004%. The highest risk locations were the vertebral artery (up to 10.3% per year) and superior cerebellar artery (up to 2.7% per year). On average, Acomm aneurysms had 1 year risk no higher than 1.1% and Pcomm aneurysms no higher than 1.2% per year. CONCLUSION: We observed that in a small retrospective series of ruptured aneurysms, the majority were <7 mm and that the theoretical rupture risk of these aneurysms, had they been discovered in the unruptured state, is low (<1% per year). Our study has a number of limitations and these results should be validated in a larger multicenter study.