Use of Indocyanine Green to Detect Intraoperative Staple-Line Leaks in Robotic Bariatric Surgery: An Observational Cohort Study.

Background Bariatric surgeries aid weight loss in patients with morbid obesity, yet staple-line leaks pose safety concerns. Multiple methods are used to help identify these links. Intraluminal indocyanine green (ICG) has been shown to be useful in other applications, and its use in robotic bariatric surgeries is underexplored. Objective The primary objective of this research project was to demonstrate the usage of intraluminal ICG in detecting staple-line leaks during robotic sleeve gastrectomy and robotic gastric bypass. Settings The research was conducted at Bronxcare Health System between June 2022 and June 2023. Methods We studied 150 consecutive participants undergoing robotic sleeve gastrectomy or robotic gastric bypass. Intraluminal ICG was used in each case in order to identify leaks. Data on comorbidities, detected intraoperative leaks, and detected postoperative leaks were collected. Results Out of the 150 patients who underwent robotic bariatric surgeries (139 for sleeve gastrectomy and 11 for gastric bypass), four cases (two for each procedure) were identified with intraoperative leaks using ICG, resulting in an overall 2.66% incidence rate. In those four patients with intraoperative leaks, reinforcing sutures and a drain were placed. Following the surgeries, none of the patients had radiologic or clinical leaks identified. Conclusions Intraluminal ICG presents a novel approach for detecting staple-line leaks in robotic bariatric surgery. Future studies can be done to look at a larger series of patients and compare leak detection rates between ICG and other methods.

Striatal mechanisms of turning behaviour following unilateral dopamine depletion in mice.

Unilateral dopamine (DA) depletion produces ipsiversive turning behaviour, and the injection of DA receptor agonists can produce contraversive turning, but the underlying mechanisms remain unclear. We conducted in vivo recording and pharmacological and optogenetic manipulations to study the role of DA and striatal output in turning behaviour. We used a video-based tracking programme while recording single unit activity in both putative medium spiny projection neurons (MSNs) and fast-spiking interneurons (FSIs) in the dorsal striatum bilaterally. Our results suggest that unilateral DA depletion reduced striatal output from the depleted side, resulting in asymmetric striatal output. Depletion systematically altered activity in both MSNs and FSIs, especially in neurons that increased firing during turning movements. Like D1 agonist SKF 38393, optogenetic stimulation in the depleted striatum increased striatal output and reversed biassed turning. These results suggest that relative striatal outputs from the two cerebral hemispheres determine the direction of turning: Mice turn away from the side of higher striatal output and towards the side of the lower striatal output.

Learning Risk-aware Costmaps for Traversability in Challenging Environments.

One of the main challenges in autonomous robotic exploration and navigation in unknown and unstructured environments is determining where the robot can or cannot safely move. A significant source of difficulty in this determination arises from stochasticity and uncertainty, coming from localization error, sensor sparsity and noise, difficult-to-model robot-ground interactions, and disturbances to the motion of the vehicle. Classical approaches to this problem rely on geometric analysis of the surrounding terrain, which can be prone to modeling errors and can be computationally expensive. Moreover, modeling the distribution of uncertain traversability costs is a difficult task, compounded by the various error sources mentioned above. In this work, we take a principled learning approach to this problem. We introduce a neural network architecture for robustly learning the distribution of traversability costs. Because we are motivated by preserving the life of the robot, we tackle this learning problem from the perspective of learning tail-risks, i.e. the conditional value-at-risk (CVaR). We show that this approach reliably learns the expected tail risk given a desired probability risk threshold between 0 and 1, producing a traversability costmap which is more robust to outliers, more accurately captures tail risks, and is more computationally efficient, when compared against baselines. We validate our method on data collected by a legged robot navigating challenging, unstructured environments including an abandoned subway, limestone caves, and lava tube caves.

Early-pregnancy prediction of risk for pre-eclampsia using maternal blood leptin/ceramide ratio: discovery and confirmation.

OBJECTIVE: This study aimed to develop a blood test for the prediction of pre-eclampsia (PE) early in gestation. We hypothesised that the longitudinal measurements of circulating adipokines and sphingolipids in maternal serum over the course of pregnancy could identify novel prognostic biomarkers that are predictive of impending event of PE early in gestation. STUDY DESIGN: Retrospective discovery and longitudinal confirmation. SETTING: Maternity units from two US hospitals. PARTICIPANTS: Six previously published studies of placental tissue (78 PE and 95 non-PE) were compiled for genomic discovery, maternal sera from 15 women (7 non-PE and 8 PE) enrolled at ProMedDx were used for sphingolipidomic discovery, and maternal sera from 40 women (20 non-PE and 20 PE) enrolled at Stanford University were used for longitudinal observation. OUTCOME MEASURES: Biomarker candidates from discovery were longitudinally confirmed and compared in parallel to the ratio of placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) using the same cohort. The datasets were generated by enzyme-linked immunosorbent and liquid chromatography-tandem mass spectrometric assays. RESULTS: Our discovery integrating genomic and sphingolipidomic analysis identified leptin (Lep) and ceramide (Cer) (d18:1/25:0) as novel biomarkers for early gestational assessment of PE. Our longitudinal observation revealed a marked elevation of Lep/Cer (d18:1/25:0) ratio in maternal serum at a median of 23 weeks' gestation among women with impending PE as compared with women with uncomplicated pregnancy. The Lep/Cer (d18:1/25:0) ratio significantly outperformed the established sFlt-1/PlGF ratio in predicting impending event of PE with superior sensitivity (85% vs 20%) and area under curve (0.92 vs 0.52) from 5 to 25 weeks of gestation. CONCLUSIONS: Our study demonstrated the longitudinal measurement of maternal Lep/Cer (d18:1/25:0) ratio allows the non-invasive assessment of PE to identify pregnancy at high risk in early gestation, outperforming the established sFlt-1/PlGF ratio test.

Small bowel intussusception in marijuana users.

Intussusception occurs when one portion of bowel 'telescopes' into another due to a lead point created by a range of benign or pathologic process. Intussusception mostly occurs in children. Although adult intussusception (AI) is rare, accounting for <5% of intestinal obstructions, it is more concerning in adults as malignancy accounts for nearly 65% of lead points in AI. Patients present with severe abdominal pain concerning for an acute abdomen along with a degree of bowel obstruction. We have experienced a total of 11 patients within recent years presenting with symptoms of an acute abdomen due to AI. None of these patients were found to have a pathologic process creating a lead point. However, we found that all of them were marijuana users. In this report, we compare their management, hospital course and review of the literature discussing proposed mechanisms that suggest an association between cannabis and intussusception.

A multidisciplinary approach to carotid body tumors surgical management.

Carotid body tumors (CBTs) are rare and usually require complex surgical resection. We present a case of a large 7-cm CBT successfully treated in a community cancer center using a multidisciplinary team approach. A 32-year-old male referred for surgical evaluation of an asymptomatic right neck mass. CT angiography showed a 7-cm tumor encasing the carotid vessels, including the bifurcation (Shamblin III). Preoperative angiography and embolization were performed by interventional radiology. The patient underwent surgical removal of the CBTs and required surgical reconstruction with a common carotid to internal carotid bypass using a polytetrafluoroethylene interposition graft. The hypoglossal nerve, vagus nerve and glossopharyngeal nerve were identified, meticulously dissected and preserved. The patient did well after surgery and recovered with no complications. This report examines the diagnosis, preoperative workup and surgical management of CBTs using a multidisciplinary team approach.

Serial-section atlas of the Tritonia pedal ganglion.

The pedal ganglion of the nudibranch gastropod Tritonia diomedea has been the focus of neurophysiological studies for more than 50 yr. These investigations have examined the neural basis of behaviors as diverse as swimming, crawling, reflex withdrawals, orientation to water flow, orientation to the earth's magnetic field, and learning. Despite this sustained research focus, most studies have confined themselves to the layer of neurons that are visible on the ganglion surface, leaving many neurons, which reside in deeper layers, largely unknown and thus unstudied. To facilitate work on such neurons, the present study used serial-section light microscopy to generate a detailed pictorial atlas of the pedal ganglion. One pedal ganglion was sectioned horizontally at 2-µm intervals and another vertically at 5-µm intervals. The resulting images were examined separately or combined into stacks to generate movie tours through the ganglion. These were also used to generate 3D reconstructions of individual neurons and rotating movies of digitally desheathed whole ganglia to reveal all surface neurons. A complete neuron count of the horizontally sectioned ganglion yielded 1,885 neurons. Real and virtual sections from the image stacks were used to reveal the morphology of individual neurons, as well as the major axon bundles traveling within the ganglion to and between its several nerves and connectives. Extensive supplemental data are provided, as well as a link to the Dryad Data Repository site, where the complete sets of high-resolution serial-section images can be downloaded. NEW & NOTEWORTHY Because of the large size and relatively low numbers of their neurons, gastropod mollusks are widely used for investigations of the neural basis of behavior. Most studies, however, focus on the neurons visible on the ganglion surface, leaving the majority, located out of sight below the surface, unexamined. The present light microscopy study generates the first detailed visual atlas of all neurons of the highly studied Tritonia pedal ganglion.

Heart-specific Rpd3 downregulation enhances cardiac function and longevity.

Downregulation of Rpd3, a homologue of mammalian Histone Deacetylase 1 (HDAC1), extends lifespan in Drosophila melanogaster. Once revealed that long-lived fruit flies exhibit limited cardiac decline, we investigated whether Rpd3 downregulation would improve stress resistance and/or lifespan when targeted in the heart. Contested against three different stressors (oxidation, starvation and heat), heart-specific Rpd3 downregulation significantly enhanced stress resistance in flies. However, these higher levels of resistance were not observed when Rpd3 downregulation was targeted in other tissues or when other long-lived flies were tested in the heart-specific manner. Interestingly, the expressions of anti-aging genes such as sod2, foxo and Thor, were systemically increased as a consequence of heart-specific Rpd3 downregulation. Showing higher resistance to oxidative stress, the heart-specific Rpd3 downregulation concurrently exhibited improved cardiac functions, demonstrating an increased heart rate, decreased heart failure and accelerated heart recovery. Conversely, Rpd3 upregulation in cardiac tissue reduced systemic resistance against heat stress with decreased heart function, also specifying phosphorylated Rpd3 levels as a significant modulator. Continual downregulation of Rpd3 throughout aging increased lifespan, implicating that Rpd3 deacetylase in the heart plays a significant role in cardiac function and longevity to systemically modulate the fly's response to the environment.

Bidirectional modulation of substantia nigra activity by motivational state.

A major output nucleus of the basal ganglia is the substantia nigra pars reticulata, which sends GABAergic projections to brainstem and thalamic nuclei. The GABAergic (GABA) neurons are reciprocally connected with nearby dopaminergic neurons, which project mainly to the basal ganglia, a set of subcortical nuclei critical for goal-directed behaviors. Here we examined the impact of motivational states on the activity of GABA neurons in the substantia nigra pars reticulata and the neighboring dopaminergic (DA) neurons in the pars compacta. Both types of neurons show short-latency bursts to a cue predicting a food reward. As mice became sated by repeated consumption of food pellets, one class of neurons reduced cue-elicited firing, whereas another class of neurons progressively increased firing. Extinction or pre-feeding just before the test session dramatically reduced the phasic responses and their motivational modulation. These results suggest that signals related to the current motivational state bidirectionally modulate behavior and the magnitude of phasic response of both DA and GABA neurons in the substantia nigra.

Secondary Sclerosing Cholangitis due to Gallbladder Adenocarcinoma.

Sclerosing cholangitis is a chronic cholestatic liver disease defined by both inflammatory and fibrotic changes of the biliary tract leading to diffuse stricture formation. This entity exists in both a primary and secondary form. Here we present a rare case of secondary sclerosing cholangitis due to direct metastasis from a gallbladder adenocarcinoma. A 55-year-old morbidly obese male presented electively with a 2-week history of low back pain and scleral icterus for 2 days. He also described severe epigastric pain that worsened postprandially and a 13 kg weight loss over the previous month. The patient denied any personal or familial history of malignancy or prior liver disease. Laboratory evaluation revealed mild elevation of transaminases with moderately elevated alkaline phosphatase and total bilirubin. Imaging included ultrasound and contrast-enhanced computed tomography of the abdomen and pelvis showing multiple large gallstones and a large tissue density mass within the fundus of the gallbladder. Subsequent endoscopic ultrasound was performed revealing celiac and portal lymphadenopathy with fine needle aspirations demonstrating adenocarcinoma. Over the next 15 days, bilirubin progressively increased. Magnetic resonance cholangiopancreatography was unremarkable. Liver biopsy, performed to exclude other etiologies of liver failure, demonstrated biliary cholestasis. Endoscopic retrograde cholangiopancreatography was then performed and an occlusion cholangiogram revealed diffuse multifocal stricturing of the intrahepatic bile ducts and moderate stenosis of the common bile duct without proximal ductal dilatation. Thus secondary sclerosing cholangitis due to gallbladder adenocarcinoma was diagnosed.

Dynamic changes in single unit activity and γ oscillations in a thalamocortical circuit during rapid instrumental learning.

The medial prefrontal cortex (mPFC) and mediodorsal thalamus (MD) together form a thalamocortical circuit that has been implicated in the learning and production of goal-directed actions. In this study we measured neural activity in both regions simultaneously, as rats learned to press a lever to earn food rewards. In both MD and mPFC, instrumental learning was accompanied by dramatic changes in the firing patterns of the neurons, in particular the rapid emergence of single-unit neural activity reflecting the completion of the action and reward delivery. In addition, we observed distinct patterns of changes in the oscillatory LFP response in MD and mPFC. With learning, there was a significant increase in theta band oscillations (6-10 Hz) in the MD, but not in the mPFC. By contrast, gamma band oscillations (40-55 Hz) increased in the mPFC, but not in the MD. Coherence between these two regions also changed with learning: gamma coherence in relation to reward delivery increased, whereas theta coherence did not. Together these results suggest that, as rats learned the instrumental contingency between action and outcome, the emergence of task related neural activity is accompanied by enhanced functional interaction between MD and mPFC in response to the reward feedback.

Mechanisms of action selection and timing in substantia nigra neurons.

The timing of actions is critical for adaptive behavior. In this study we measured neural activity in the substantia nigra as mice learned to change their action duration to earn food rewards. We observed dramatic changes in single unit activity during learning: both dopaminergic and GABAergic neurons changed their activity in relation to behavior to reflect the learned instrumental contingency and the action duration. We found the emergence of "action-on" neurons that increased firing for the duration of the lever press and mirror-image "action-off" neurons that paused at the same time. This pattern is especially common among GABAergic neurons. The activity of many neurons also reflected confidence about the just completed action and the prospect of reward. Being correlated with the relative duration of the completed action, their activity could predict the likelihood of reward collection. Compared with the GABAergic neurons, the activity of dopaminergic neurons was more commonly modulated by the discriminative stimulus signaling the start of each trial, suggesting that their phasic activity reflected sensory salience rather than any reward prediction error found in previous work. In short, these results suggest that (1) nigral activity is highly plastic and modified by the learning of the instrumental contingency; (2) GABAergic output from the substantia nigra can simultaneously inhibit and disinhibit downstream structures, while the dopaminergic output also provide bidirectional modulation of the corticostriatal circuits; (3) dopaminergic and GABAergic neurons show similar task-related activity, although DA neurons are more responsive to the trial start signal.

Predictors of supportive message expression and reception in an interactive cancer communication system.

Social support in computer-mediated settings is an important variable in health communication research, yet little is known about the factors that influence the amount of social support one gives and receives in online support groups. To shed some light on this issue, the authors examined demographics, disease-related factors, psychosocial factors, and strategies for coping with breast cancer as potential determinants of which patients provide support to others and which ones consume it. Data collected from 177 participants in the Comprehensive Health Enhancement Support System "Living With Breast Cancer" program revealed that individuals who are younger, have higher levels of positive reframing, and lower levels of self-blame are more likely to provide emotional support in online settings. In contrast, individuals who are more educated, have less perceived availability of social support, and have lower levels of religious coping are more likely to receive emotional support from others. The authors discuss the theoretical and practical implications for providing effective psychosocial support for women with breast cancer.

Motivational state and reward content determine choice behavior under risk in mice.

Risk is a ubiquitous feature of the environment for most organisms, who must often choose between a small and certain reward and a larger but less certain reward. To study choice behavior under risk in a genetically well characterized species, we trained mice (C57BL/6) on a discrete trial, concurrent-choice task in which they must choose between two levers. Pressing one lever (safe choice) is always followed by a small reward. Pressing the other lever (risky choice) is followed by a larger reward, but only on some of the trials. The overall payoff is the same on both levers. When mice were not food deprived, they were indifferent to risk, choosing both levers with equal probability regardless of the level of risk. In contrast, following food or water deprivation, mice earning 10% sucrose solution were risk-averse, though the addition of alcohol to the sucrose solution dose-dependently reduced risk aversion, even before the mice became intoxicated. Our results falsify the budget rule in optimal foraging theory often used to explain behavior under risk. Instead, they suggest that the overall demand or desired amount for a particular reward determines risk preference. Changes in motivational state or reward identity affect risk preference by changing demand. Any manipulation that increases the demand for a reward also increases risk aversion, by selectively increasing the frequency of safe choices without affecting frequency of risky choices.

A wireless multi-channel recording system for freely behaving mice and rats.

To understand the neural basis of behavior, it is necessary to record brain activity in freely moving animals. Advances in implantable multi-electrode array technology have enabled researchers to record the activity of neuronal ensembles from multiple brain regions. The full potential of this approach is currently limited by reliance on cable tethers, with bundles of wires connecting the implanted electrodes to the data acquisition system while impeding the natural behavior of the animal. To overcome these limitations, here we introduce a multi-channel wireless headstage system designed for small animals such as rats and mice. A variety of single unit and local field potential signals were recorded from the dorsal striatum and substantia nigra in mice and the ventral striatum and prefrontal cortex simultaneously in rats. This wireless system could be interfaced with commercially available data acquisition systems, and the signals obtained were comparable in quality to those acquired using cable tethers. On account of its small size, light weight, and rechargeable battery, this wireless headstage system is suitable for studying the neural basis of natural behavior, eliminating the need for wires, commutators, and other limitations associated with traditional tethered recording systems.

Expression and reception of treatment information in breast cancer support groups: how health self-efficacy moderates effects on emotional well-being.

OBJECTIVES: To examine the effects of exchanging treatment information within computer-mediated breast cancer support groups on emotional well-being, and to explore whether this relationship is moderated by health self-efficacy. SAMPLE: 177 breast cancer patients using an electronic Health (eHealth) program with discussion group. MEASURE: expression and reception of treatment information; emotional well-being scale (0, 4 months). ANALYSES: hierarchical regression. RESULTS: Effects of expression and reception of treatment information on emotional well-being were significantly greater for those who have higher health self-efficacy. CONCLUSIONS: Results conditionally support prior research finding positive effects of treatment information exchanges among breast cancer patients. Such exchanges had a positive impact on emotional well-being for those with higher health self-efficacy, but they had a negative influence for those with lower health self-efficacy. PRACTICE IMPLICATIONS: Given that the association between emotional well-being and exchanging treatment information was moderated by health self-efficacy, clinicians should explain the role of health self-efficacy before encouraging patients to use eHealth systems for treatment exchanges.

Instrumental uncertainty as a determinant of behavior under interval schedules of reinforcement.

Interval schedules of reinforcement are known to generate habitual behavior, the performance of which is less sensitive to revaluation of the earned reward and to alterations in the action-outcome contingency. Here we report results from experiments using different types of interval schedules of reinforcement in mice to assess the effect of uncertainty, in the time of reward availability, on habit formation. After limited training, lever pressing under fixed interval (FI, low interval uncertainty) or random interval schedules (RI, higher interval uncertainty) was sensitive to devaluation, but with more extended training, performance of animals trained under RI schedules became more habitual, i.e. no longer sensitive to devaluation, whereas performance of those trained under FI schedules remained goal-directed. When the press-reward contingency was reversed by omitting reward after pressing but presenting reward in the absence of pressing, lever pressing in mice previously trained under FI decreased more rapidly than that of mice trained under RI schedules. Further analysis revealed that action-reward contiguity is significantly reduced in lever pressing under RI schedules, whereas action-reward correlation is similar for the different schedules. Thus the extent of goal-directedness could vary as a function of uncertainty about the time of reward availability. We hypothesize that the reduced action-reward contiguity found in behavior generated under high uncertainty is responsible for habit formation.

Forest value orientations in Australia: an application of computer content analysis.

This article explores the expression of three forest value orientations that emerged from an analysis of Australian news media discourse about the management of Australian native forests from August 1, 1997 through December 31, 2004. Computer-coded content analysis was used to measure and track the relative importance of commodity, ecological and moral/spiritual/aesthetic forest value orientations. The number of expressions of these forest value orientations followed major events in forest management and policy, with peaks corresponding to finalization of Regional Forest Agreements and conflicts over forest management. Over the time period analyzed, the relative share of commodity value orientation decreased and the shares of the ecological and moral/spiritual/aesthetic value orientations increased. The shifts in forest value orientations highlight the need for native forests to be managed for multiple values and the need for continued monitoring of forest values.

Pharmacogenomics and the Yin/Yang actions of ginseng: anti-tumor, angiomodulating and steroid-like activities of ginsenosides.

In Chinese medicine, ginseng (Panax ginseng C.A. Meyer) has long been used as a general tonic or an adaptogen to promote longevity and enhance bodily functions. It has also been claimed to be effective in combating stress, fatigue, oxidants, cancer and diabetes mellitus. Most of the pharmacological actions of ginseng are attributed to one type of its constituents, namely the ginsenosides. In this review, we focus on the recent advances in the study of ginsenosides on angiogenesis which is related to many pathological conditions including tumor progression and cardiovascular dysfunctions. Angiogenesis in the human body is regulated by two sets of counteracting factors, angiogenic stimulators and inhibitors. The 'Yin and Yang' action of ginseng on angiomodulation was paralleled by the experimental data showing angiogenesis was indeed related to the compositional ratio between ginsenosides Rg1 and Rb1. Rg1 was later found to stimulate angiogenesis through augmenting the production of nitric oxide (NO) and vascular endothelial growth factor (VEGF). Mechanistic studies revealed that such responses were mediated through the PI3K-->Akt pathway. By means of DNA microarray, a group of genes related to cell adhesion, migration and cytoskeleton were found to be up-regulated in endothelial cells. These gene products may interact in a hierarchical cascade pattern to modulate cell architectural dynamics which is concomitant to the observed phenomena in angiogenesis. By contrast, the anti-tumor and anti-angiogenic effects of ginsenosides (e.g. Rg3 and Rh2) have been demonstrated in various models of tumor and endothelial cells, indicating that ginsenosides with opposing activities are present in ginseng. Ginsenosides and Panax ginseng extracts have been shown to exert protective effects on vascular dysfunctions, such as hypertension, atherosclerotic disorders and ischemic injury. Recent work has demonstrates the target molecules of ginsenosides to be a group of nuclear steroid hormone receptors. These lines of evidence support that the interaction between ginsenosides and various nuclear steroid hormone receptors may explain the diverse pharmacological activities of ginseng. These findings may also lead to development of more efficacious ginseng-derived therapeutics for angiogenesis-related diseases.