Artificial intelligence in the fertility clinic: status, pitfalls and possibilities.

In recent years, the amount of data produced in the field of ART has increased exponentially. The diversity of data is large, ranging from videos to tabular data. At the same time, artificial intelligence (AI) is progressively used in medical practice and may become a promising tool to improve success rates with ART. AI models may compensate for the lack of objectivity in several critical procedures in fertility clinics, especially embryo and sperm assessments. Various models have been developed, and even though several of them show promising performance, there are still many challenges to overcome. In this review, we present recent research on AI in the context of ART. We discuss the strengths and weaknesses of the presented methods, especially regarding clinical relevance. We also address the pitfalls hampering successful use of AI in the clinic and discuss future possibilities and important aspects to make AI truly useful for ART.

Crural Closure improves Outcomes of Magnetic Sphincter Augmentation in GERD patients with Hiatal Hernia.

Magnetic sphincter-augmentation (MSA) has been proven effective in the treatment of GERD. No consensus exists on whether crural closure should be performed. Our aim was to assess the impact of cruroplasty on reflux-control and quality of life. MSA-Patients treated between 03/2012-03/2017 were classified into those without hiatal hernia ("NHH"), those post-MSA (NHR) and those post-MSA/hiatal repair (HR). GERD-symptoms, PPI-intake, GERD-Health-related-Quality-of-Life (GERD-HRQL) and Alimentary Satisfaction were assessed. Sixty-eight patients underwent MSA, 26 patients had additional crural closure. PH-monitoring was negative in 80% of HR, 73% of NHR and 89% of NHH-patients. GERD-HRQL-total scores decreased significantly in all groups (p < 0.001). Alimentary satisfaction was 8/10 in HR/NHH and 10/10 in NHR-patients. Satisfaction with heartburn relief was high (HR: 96%, NR: 95%, NHH: 94%) as was the elimination of PPI-intake (HR/NHH: 87%, NR: 86%). Heartburn and regurgitations were eliminated in 100% of HR, 88% and 94% of NHR and 87% and 91% of NHH-patients. Endoscopic dilatation or device explantation was performed in 3% each. MSA leads to significant symptom relief, increased quality of life and alimentary satisfaction with low perioperative morbidity. Cruroplasty tends to result in better reflux control and symptom relief than exclusive MSA without increasing dysphagia rates.

Dietary sugar and Barrett's esophagus.

INTRODUCTION: Barrett's esophagus (BE) represents the premalignant morphology of gastroesophageal reflux disease (GERD). Evidence indicates a positive correlation between GERD vs. obesity and increased sugar consumption. METHODS: Here we analyzed recently published data (2006-2017) on the role of dietary sugar intake for BE development (main focus year 2017). RESULTS: Recent investigations found a positive association between obesity, hip waist ratio and dietary sugar intake and Barrett's esophagus. CONCLUSION: Sugar intake positively associates with BE. A low carbohydrate diet should be recommended for persons with BE and GERD.

Update on the management of Barrett's esophagus in Austria.

BACKGROUND: Barrett's esophagus (BE) is the premalignant manifestation of gastroesophageal reflux disease (GERD). Radiofrequency ablation (RFA) with and without endoscopic resection (ER) is a novel treatment for BE. METHODS: Here we present a single-center update of the recommendations of a recent (June 2015) interdisciplinary expert panel meeting on the management of BE with dysplasia as well as cancer-positive and cancer-negative BE. We conducted a PubMed search of studies published in 2016 and 2017 on the topic of BE and RFA. RESULTS: Our update reconfirms that BE positive for T1a cancer as well as low- and high-grade dysplasia justifies the use of RFA ± ER, offering an 80-100% rate of BE clearance. RFA ± ER of dysplastic BE is tenfold more effective for cancer prevention when compared with surveillance. Risk factors for recurrence and follow-up treatments include baseline histopathology (dysplasia/T1a cancer), esophagitis, hiatal hernia >3 cm, smoking habits, BE segments >3 cm, and >10 years of GERD symptoms. A baseline diagnosis for dysplasia and T1a cancer should include a second expert pathologist opinion. Recent data justify the use of RFA for nondysplastic BE only in controlled clinical trials. Antireflux surgery can be offered to those with function-test-proven, GERD-symptom-positive BE before, during, or after RFA ± ER. Additionally, there is growing evidence that the intake of a sugar-rich diet is positively correlated with the development of GERD, BE, and cancer. CONCLUSION: RFA ± ER should be offered for dysplastic BE and T1a cancer after ER as well as for nondysplastic BE with additional risk factors in controlled trials. Antireflux surgery can be offered to patients with function-test-proven GERD-symptom-positive BE. Diet considerations should be included in the management of GERD and BE.

Local coexistence and genetic isolation of three pollinator species on the same fig tree species.

Molecular tools increasingly reveal cryptic lineages and species that were previously unnoticed by traditional taxonomy. The discovery of cryptic species in sympatry prompts the question of how they coexist in the apparent absence of ecological divergence. However, this assumes first that the molecular taxonomy used to identify cryptic lineages delimits species boundaries accurately. This issue is important, because many diversity studies rely heavily or solely on data from mitochondrial DNA sequences for species delimitation, and several factors may lead to poor identification of species boundaries. We used a multilocus population genetics approach to show that three mtDNA-defined cryptic lineages of the fig wasp Pleistodontes imperialis Saunders, which pollinate Port Jackson figs (Ficus rubiginosa) in north-eastern Australia, represent reproductively isolated species. These species coexist locally, with about 13% of figs (where mating occurs) containing wasps from two or three species. However, there was no evidence for gene flow between them. Confirmed cases of coexisting cryptic species provide excellent opportunities for future studies of the ecological and evolutionary forces shaping both species coexistence and fig/pollinator coevolution.

Waist to hip ratio is a better predictor of esophageal acid exposure than body mass index.

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are major health problems showing an inconstant relationship in the literature. Therefore, anthropometric parameters which are predictive and can simply be assessed at first patient presentation may lead to a better patient selection for ambulatory reflux monitoring. We aimed to examine the association of body mass index (BMI) and waist to hip ratio (WHR) with gastroesophageal reflux activity during 24 hour-pH-impedance monitoring. METHODS: Seven hundred and seventy-one patients with GERD symptoms underwent 24 hour-pH-impedance monitoring and high resolution manometry off proton pump inhibitors. Patients with known primary motility disorders of the esophagus and pre-existing endoscopic or operative procedure on esophagus or stomach were excluded from the study. Reflux parameters and anthropometric and demographic data from our prospectively gathered database were analyzed. We performed univariate and multivariate regression analysis to evaluate the associations of BMI and WHR with reflux parameters measured with 24 hour-pH-impedance monitoring. KEY RESULTS: WHR showed a significantly stronger association with esophageal acid exposure than BMI (P<.001). Our data show that 6.9% of the percentage of endoluminal pH<4 in the distal esophagus is attributable to WHR. Furthermore, an association of WHR with impaired esophageal acid clearance was observed. Additionally, we observed an inverse relationship between lower esophageal sphincter integrity (P=.05) and esophageal acid exposure. CONCLUSIONS AND INFERENCES: WHR is a better predictor for esophageal acid exposure than BMI. Biomechanical and metabolic mechanisms of central fat distribution may influence reflux parameters in 24 hour pH impedance monitoring, which may affect patient selection for ambulatory reflux monitoring.

The Microbiome of Field-Caught and Laboratory-Adapted Australian Tephritid Fruit Fly Species with Different Host Plant Use and Specialisation.

Tephritid fruit fly species display a diversity of host plant specialisation on a scale from monophagy to polyphagy. Furthermore, while some species prefer ripening fruit, a few are restricted to damaged or rotting fruit. Such a diversity of host plant use may be reflected in the microbial symbiont diversity of tephritids and their grade of dependency on their microbiomes. Here, we investigated the microbiome of six tephritid species from three genera, including species that are polyphagous pests (Bactrocera tryoni, Bactrocera neohumeralis, Bactrocera jarvisi, Ceratitis capitata) and a monophagous specialist (Bactrocera cacuminata). These were compared with the microbiome of a non-pestiferous but polyphagous tephritid species that is restricted to damaged or rotting fruit (Dirioxa pornia). The bacterial community associated with whole fruit flies was analysed by 16S ribosomal DNA (rDNA) amplicon pyrosequencing to detect potential drivers of taxonomic composition. Overall, the dominant bacterial families were Enterobacteriaceae and Acetobacteraceae (both Proteobacteria), and Streptococcaceae and Enterococcaceae (both Firmicutes). Comparisons across species and genera found different microbial composition in the three tephritid genera, but limited consistent differentiation between Bactrocera species. Within Bactrocera species, differentiation of microbial composition seemed to be influenced by the environment, possibly including their diets; beyond this, tephritid species identity or ecology also had an effect. The microbiome of D. pornia was most distinct from the other five species, which may be due to its ecologically different niche of rotting or damaged fruit, as opposed to ripening fruit favoured by the other species. Our study is the first amplicon pyrosequencing study to compare the microbiomes of tephritid species and thus delivers important information about the turnover of microbial diversity within and between fruit fly species and their potential application in pest management strategies.

Nutritional enhancement of leaves by a psyllid through senescence-like processes: insect manipulation or plant defence?

Some herbivores can modify the physiology of plant modules to meet their nutritional requirements. Induction of premature leaf senescence could benefit herbivores since it is associated with the mobilisation of nutrients. We compared the effects of nymphal feeding by Cardiaspina near densitexta on Eucalyptus moluccana with endogenous processes associated with senescence to assess the relative merits of an insect manipulation or plant defence interpretation of responses. Evidence supporting insect manipulation included increased size of fourth and fifth instar nymphs (in the latter the effect was restricted to forewing pad length of females) on leaves supporting high numbers of conspecifics and feeding preventing leaf necrosis. Intra-specific competition negated greater performance at very high densities. High and very high abundances of nymphs were associated with increased concentrations of amino acid N but only very high abundances of nymphs tended to be associated with increased concentrations of six essential amino acids. Contrary to the insect manipulation interpretation, feeding by very high abundances of nymphs was associated with significant reductions in chlorophyll, carotenoids and anthocyanins. Evidence supporting plant defence included the severity of chlorosis increasing with the abundance of nymphs. Leaf reddening did not develop because ambient conditions associated with photoinhibition (high irradiance and low temperature) were not experienced by leaves with chlorotic lesions. Leaf reddening (from anthocyanins) alone is not expected to adversely affect nymphal survival; only leaf necrosis would kill nymphs. For senescence-inducing psyllids, nutritional enhancement does not fit neatly into either an insect manipulation or plant defence interpretation.

Expression patterns of sex-determination genes in single male and female embryos of two Bactrocera fruit fly species during early development.

In tephritids, the sex-determination pathway follows the sex-specific splicing of transformer (tra) mRNA, and the cooperation of tra and transformer-2 (tra-2) to effect the sex-specific splicing of doublesex (dsx), the genetic double-switch responsible for male or female somatic development. The Dominant Male Determiner (M) is the primary signal that controls this pathway. M, as yet uncharacterized, is Y-chromosome linked, expressed in the zygote and directly or indirectly diminishes active TRA protein in male embryos. Here we first demonstrated the high conservation of tra, tra-2 and dsx in two Australian tephritids, Bactrocera tryoni and Bactrocera jarvisi. We then used quantitative reverse transcription PCR on single, sexed embryos to examine expression of the key sex-determination genes during early embryogenesis. Individual embryos were sexed using molecular markers located on the B. jarvisi Y-chromosome that was also introgressed into a B. tryoni line. In B. jarvisi, sex-specific expression of tra transcripts occurred between 3 to 6 h after egg laying, and the dsx isoform was established by 7 h. These milestones were delayed in B. tryoni lines. The results provide a time frame for transcriptomic analyses to identify M and its direct targets, plus information on genes that may be targeted for the development of male-only lines for pest management.

[Critical assessment of a new endoscopic anatomic concept for the so-called cardia in the sense of the notions of Parmenides and Martin Heidegger]. / Kritische Betrachtung neuer Konzepte zur endoskopischen Anatomie des ösphagogastralen Übergangs im Sinne des Denkens von Parmenides und Martin Heidegger.

Current endoscopic anatomy interposes the gastric cardia between the tubular oesophagus and the proximal stomach. In contrast to that, recent evidence unfolds a different view. Using "PubMed" and "Scopus" searches, we examined if the novel understanding regarding the cardia goes in line with the concept of unfolding, as described by Heidegger based on the ancient didactic poetry of Parmenides. What has been taken as gastric cardia in fact represents reflux-damaged, dilated, columnar lined oesophagus (CLO): dilated distal oesophagus (DDO). Due to its macroscopic gastric appearance it cannot be discriminated from the stomach by endoscopy. Differentiation between DDE and proximal stomach requires the histopathology of measured multi-level biopsies obtained from the DDO and the proximal stomach. Cardaic, onxytocardiac mucosa and intestinal metaplasia (IM; Barrett's oesophagus) define CLO and thus the oesophageal location, while oxyntic mucosa (OM) of the proximal stomach verifies a gastric biopsy location. Endoscopically visible CLO and DDO define the morphological manifestation of reflux: the squamo-oxyntic gap (SOG). Biopsies obtained from the level of the diaphragmatic impressions allow differentiation between an enlarged hiatus with normal anatomic content (CLO; oesophagus) vs. hernia with abnormal content (OM; stomach). Non-dysplastic Barrett's oesophagus exists in 10 %-17 % of asymptomatic and in 20 %-100 % (with increasing CLO length) of reflux symptom-positive individuals (annual cancer risk: 0.2 %-0.7 %). These data justify biopsy of an endoscopically normal appearing squamocolumnar junction for the exclusion of Barrett's oesophagus and cancer risk. In the absence of contraindications, cancer risk-based therapy of dysplastic Barrett's oesophagus includes radiofrequency ablation (RFA) ± endoscopic resection. The perception of the cardia as reflux damaged DDO mirrors the concept of unfolding, as described by the interpretation of the didactic poem of Parmenides by Heidegger. Our data recommend to omit the term "cardia" and allocate morphology either to the oesophagus (CLO, DDO) or to the proximal stomach or indicate that allocation is impossible (i. e.. tumour-induced). Future studies will have to test the value of this novel concept for diagnosis, treatment of gastro-oesophageal reflux disease and cancer prevention.

Tropical tephritid fruit fly community with high incidence of shared Wolbachia strains as platform for horizontal transmission of endosymbionts.

Wolbachia are endosymbiotic bacteria that infect 40-65% of arthropod species. They are primarily maternally inherited with occasional horizontal transmission for which limited direct ecological evidence exists. We detected Wolbachia in 8 out of 24 Australian tephritid species. Here, we have used multilocus sequence typing (MLST) to further characterize these Wolbachia strains, plus a novel quantitative polymerase chain reaction method for allele assignment in multiple infections. Based on five MLST loci and the Wolbachia surface protein gene (wsp), five Bactrocera and one Dacus species harboured two identical strains as double infections; furthermore, Bactrocera neohumeralis harboured both of these as single or double infections, and sibling species B. tryoni harboured one. Two Bactrocera species contained Wolbachia pseudogenes, potentially within the fruit fly genomes. A fruit fly parasitoid, Fopius arisanus shared identical alleles with two Wolbachia strains detected in one B. frauenfeldi individual. We report an unprecedented high incidence of four shared Wolbachia strains in eight host species from two trophic levels. This suggests frequent exposure to Wolbachia in this tropical tephritid community that shares host plant and parasitoid species, and also includes species that hybridize. Such insect communities may act as horizontal transmission platforms that contribute to the ubiquity of the otherwise maternally inherited Wolbachia.

Interactive direct and plant-mediated effects of elevated atmospheric [CO2 ] and temperature on a eucalypt-feeding insect herbivore.

Understanding the direct and indirect effects of elevated [CO2 ] and temperature on insect herbivores and how these factors interact are essential to predict ecosystem-level responses to climate change scenarios. In three concurrent glasshouse experiments, we measured both the individual and interactive effects of elevated [CO2 ] and temperature on foliar quality. We also assessed the interactions between their direct and plant-mediated effects on the development of an insect herbivore of eucalypts. Eucalyptus tereticornis saplings were grown at ambient or elevated [CO2 ] (400 and 650 µmol mol(-1) respectively) and ambient or elevated ( + 4 °C) temperature for 10 months. Doratifera quadriguttata (Lepidoptera: Limacodidae) larvae were feeding directly on these trees, on their excised leaves in a separate glasshouse, or on excised field-grown leaves within the temperature and [CO2 ] controlled glasshouse. To allow insect gender to be determined and to ensure that any sex-specific developmental differences could be distinguished from treatment effects, insect development time and consumption were measured from egg hatch to pupation. No direct [CO2 ] effects on insects were observed. Elevated temperature accelerated larval development, but did not affect leaf consumption. Elevated [CO2 ] and temperature independently reduced foliar quality, slowing larval development and increasing consumption. Simultaneously increasing both [CO2 ] and temperature reduced these shifts in foliar quality, and negative effects on larval performance were subsequently ameliorated. Negative nutritional effects of elevated [CO2 ] and temperature were also independently outweighed by the direct positive effect of elevated temperature on larvae. Rising [CO2 ] and temperature are thus predicted to have interactive effects on foliar quality that affect eucalypt-feeding insects. However, the ecological consequences of these interactions will depend on the magnitude of concurrent temperature rise and its direct effects on insect physiology and feeding behaviour.

Interactive effects of pre-industrial, current and future [CO2] and temperature on an insect herbivore of Eucalyptus.

Both atmospheric [CO2] and average surface temperatures are predicted to increase with potentially different, additive or opposing, effects on leaf quality and insect herbivore activity. Few studies have directly measured the interactive effects of concurrent changes in [CO2] and temperature on insect herbivores. None have done so over the entire developmental period of a tree-feeding insect, and none have compared responses to low pre-industrial [CO2] and present day [CO2] to estimate responses to future increases. Eucalypt herbivores may be particularly sensitive to climate-driven shifts in plant chemistry, as eucalypt foliage is naturally low in [N]. In this study, we assessed the development of the eucalypt herbivore Doratifera quadriguttata exposed concurrently to variable [CO2] (290, 400, 650 µmol mol(-1)) and temperature (ambient, ambient +4 °C) on glasshouse-grown Eucalyptus tereticornis. Overall, insects performed best on foliage grown at pre-industrial [CO2], indicating that modern insect herbivores have already experienced nutritional shifts since industrialisation. Rising [CO2] increased specific leaf mass and leaf carbohydrate concentration, subsequently reducing leaf [N]. Lower leaf [N] induced compensatory feeding and impeded insect performance, particularly by prolonging larval development. Importantly, elevated temperature dampened the negative effects of rising [CO2] on larval performance. Therefore, rising [CO2] over the past 200 years may have reduced forage quality for eucalypt insects, but concurrent temperature increases may have partially compensated for this, and may continue to do so in the future. These results highlight the importance of assessing plant-insect interactions within the context of multiple climate-change factors because of the interactive and potentially opposing effects of different factors within and between trophic levels.

Is there a role for dynamic swallowing MRI in the assessment of gastroesophageal reflux disease and oesophageal motility disorders?

OBJECTIVES: To evaluate the diagnostic value of dynamic MRI swallowing in patients with symptoms of Gastroesophageal Reflux Disease (GERD). METHODS: Thirty-seven patients (17 m/20f) with typical signs of GERD underwent MR swallowing in the supine position at 1.5 T with a phased-array body coil. Using dynamic, gradient echo sequences (B-FFE) in the coronal, sagittal and axial planes, the bolus passages of buttermilk spiked with gadolinium chelate were tracked. MRI, pH-metry and manometry were performed within 31 days and results were compared. RESULTS: MRI results were concordant with pH-metry in 82% (23/28) of patients diagnosed with abnormal oesophageal acid exposure by pH-metry. Five patients demonstrated typical symptoms of GERD and had positive findings with pH monitoring, but false negative results with MRI. In four of six patients (67%), there was a correct diagnosis of oesophageal motility disorder, according to manometric criteria, on dynamic MRI. The overall accuracy of MRI diagnoses was 79% (27/34). A statistically significant difference was found between the size of hiatal hernia, grade of reflux in MRI, and abnormal acid exposure on pH-monitoring. CONCLUSIONS: MR fluoroscopy may be a promising radiation-free tool in assessing the functionality and morphology of the GE junction. KEY POINTS: • Swallowing MRI can assess anatomy and function of the gastroesophageal-junction • Swallowing MRI can help identifying reflux and motility disorders • Definition of the size of hiatal hernias is possible in all three planes in MR. • Short duration of swallowing MRI enables its application in routine clinical practice.

HER-2 status in primary oesophageal cancer, lymph nodes and distant metastases.

BACKGROUND: Some 10-15 per cent of patients with oesophageal cancer overexpress human epidermal growth factor receptor (HER) 2 at the primary tumour site, leading to the hope that specific targeted systemic therapy might favourably influence clinical and subclinical disease at locoregional and distant sites. This approach is based on primary tumour characteristics, without knowledge of expression patterns at metastatic sites. In oesophageal cancer, concordance between HER-2 status at the primary tumour and other sites is unknown. METHODS: The HER-2 status of primary tumours and corresponding metastatic sites (lymph node and distant) and local recurrence were evaluated in a series of patients with oesophageal cancer, using immunohistochemistry and dual colorimetric in situ hybridization. RESULTS: There were 97 adenocarcinomas (ACs) and 79 squamous cell carcinomas (SCCs). Some 14 per cent of primary ACs and 1 per cent of primary SCCs were staged as HER-2-positive. The HER-2 status was identical in the primary tumour and lymph node metastases in 95 per cent of ACs and 99 per cent of SCCs respectively (P = 0·375, sign test). Nineteen of 22 distant metastases from AC and all from SCC had identical HER-2 status to the primary tumour. In two of 22 patients with AC the primary tumour was classed as negative but distant metastases were HER-2-positive. CONCLUSION: With over 85 per cent concordance in HER-2 status between primary tumours and distant metastases in oesophageal cancer, routine HER-2 testing of metastases to confirm HER-2 positivity is not warranted. Assessment of HER-2 status at metastatic sites may be worthwhile in some patients with easily accessible metastases and negative HER-2 status at the primary tumour, or if adequate material cannot be obtained from the primary site.