Complications in Patients with Surgically Altered Gastrointestinal Anatomy Undergoing Endoscopic Retrograde Cholangiopancreatography: 15-Year Experience at a Tertiary Care Center in Latin America.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure, but it poses challenges in patients with surgically altered gastrointestinal anatomy (SAGA). Alternative techniques like single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or push enteroscopy (PE) have been used, albeit with potential complications. Limited Latin American data exists on ERCP complications in SAGA patients. Our goal is to describe complications of ERCP in SAGA at a national referral institution. METHODS: Retrospective, single-center cohort study. All SAGA ERCP procedures performed at the Gastrointestinal Endoscopy Department of the National Institute of Medical Sciences and Nutrition Salvador Zubirán from January 2008 to May 2023 were included. Extracted data from records included procedure specifics, endoscope type, success, and complications. Complications were evaluated during procedure and 28-day post-procedure and classified using the AGREE system. RESULTS: A total of 266 procedures in 174 patients were included, 74% were women, and the median age was 44 years. Predominant modified anatomy was Roux-en-Y biliary reconstruction (79%), followed by Whipple procedure (13%) and subtotal gastrectomy with Roux-en-Y reconstruction (6.0%). The main indications were cholangitis with stricture (31%), stricture (19%), and cholangitis (19%). DBE was used in 89%, PE in 7.5%, and SBE in 3.4%. Success rates were 77% endoscopic, 72% technical, and 69% therapeutic; in 30%, the procedure was unsuccessful. Complications happened in 18% of cases, most commonly cholangitis (7.5%), followed by perforation (2.6%) and hemorrhage (1.9%). According to the AGREE classification, 10.9% were grades 1 and 2, 6.4% were grade 3, and 0.4% were grade 4 complications. No significant differences emerged between groups with and without complications. Procedures increased over time, but complications and unsuccessful procedures remained stable. CONCLUSION: ERCP complications align with international data, often not requiring invasive treatment. Enhanced exposure to such cases correlates with fewer complications and failures. Prospective studies are essential to identify complication and failure predictors.

Protein-losing enteropathy secondary to graft-versus-host disease.

Protein-losing enteropathy is a gastrointestinal complication of Graft versus host disease. The clinical presentation can be similar to that of multiple pathologies and represents a diagnostic challenge for clinicians. We report a 23-year-old man with a history of acute lymphoid leukemia that required allogeneic hematopoietic stem cell transplantation that came to evaluation due to anasarca. We report a 23-year-old man with a history of acute lymphoid leukemia who required allogeneic hematopoietic stem cell transplantation and came to evaluation due to anasarca.

Protein-losing enteropathy secondary to graft-versus-host disease

Protein-losing enteropathy is a gastrointestinal complication of Graft versus host disease. The clinical presentation can be similar to that of multiple pathologies and represents a diagnostic challenge for clinicians. We report a 23-year-old man with a history of acute lymphoid leukemia that required allogeneic hematopoietic stem cell transplantation that came to evaluation due to anasarca. We report a 23-year-old man with a history of acute lymphoid leukemia who required allogeneic hematopoietic stem cell transplantation and came to evaluation due to anasarca. (AU)

Development and Evaluation of a Low-Cost Triglyceride Quantification Enzymatic Biosensor Using an Arduino-Based Microfluidic System.

Overweight and obesity promote diabetes and heart disease onset. Triglycerides are key biomarkers for cardiovascular disease, strokes, and other health issues. Scientists have devised methods and instruments for the detection of these molecules in liquid samples. In this study, an enzymatic biosensor was developed using an Arduino-based microfluidic platform, wherein a lipolytic enzyme was immobilized on an ethylene-vinyl acetate polymer through physical adsorption. This low-cost optical biosensor employed a spectrophotometric transducer and was assessed in liquid samples to indirectly detect triglycerides and fatty acids using p-nitrophenol as an indicator. The average triglyceride level detected in the conducted experiments was 47.727 mg/dL. The biosensor exhibited a percentage of recovery of 81.12% and a variation coefficient of 0.791%. Furthermore, the biosensor demonstrated the ability to detect triglyceride levels without the need for sample dilution, ranging from 7.6741 mg/dL to 58.835 mg/dL. This study successfully developed an efficient and affordable enzymatic biosensor prototype for triglyceride and fatty acid detection. The lipolytic enzyme immobilization on the polymer substrate provided a stable and reproducible detection system, rendering this biosensor an exciting option for the detection of these molecules.

Vestigial-dependent induction contributes to robust patterning but is not essential for wing-fate recruitment in Drosophila.

Cell recruitment is a process by which a differentiated cell induces neighboring cells to adopt its same cell fate. In Drosophila, cells expressing the protein encoded by the wing selector gene, vestigial (vg), drive a feed-forward recruitment signal that expands the Vg pattern as a wave front. However, previous studies on Vg pattern formation do not reveal these dynamics. Here, we use live imaging to show that multiple cells at the periphery of the wing disc simultaneously activate a fluorescent reporter of the recruitment signal, suggesting that cells may be recruited without the need for their contact neighbors be recruited in advance. In support of this observation, when Vg expression is inhibited either at the dorsal-ventral boundary or away from it, the activation of the recruitment signal still occurs at a distance, suggesting that Vg expression is not absolutely required to send or propagate the recruitment signal. However, the strength and extent of the recruitment signal is clearly compromised. We conclude that a feed-forward, contact-dependent cell recruitment process is not essential for Vg patterning, but it is necessary for robustness. Overall, our findings reveal a previously unidentified role of cell recruitment as a robustness-conferring cell differentiation mechanism.

Individual bias and fluctuations in collective decision making: from algorithms to Hamiltonians.

In this paper, we reconsider the spin model suggested recently to understand some features of collective decision making among higher organisms (Hartnettet al2016Phys. Rev. Lett.116038701). Within the model, the state of an agentiis described by the pair of variables corresponding to its opinionSi=±1and a biasωitoward any of the opposing values ofSi. Collective decision making is interpreted as an approach to the equilibrium state within the nonlinear voter model subject to a social pressure and a probabilistic algorithm. Here, we push such a physical analogy further and give the statistical physics interpretation of the model, describing it in terms of the Hamiltonian of interaction and looking for the equilibrium state via explicit calculation of its partition function. We show that, depending on the assumptions about the nature of social interactions, two different Hamiltonians can be formulated, which can be solved using different methods. In such an interpretation the temperature serves as a measure of fluctuations, not considered before in the original model. We find exact solutions for the thermodynamics of the model on the complete graph. The general analytical predictions are confirmed using individual-based simulations. The simulations also allow us to study the impact of system size and initial conditions on the collective decision making in finite-sized systems, in particular, with respect to convergence to metastable states.

Phlegmonous gastritis associated with invasive Pseudomonas aeruginosa infection.

We report the case of a 49 years-old female that was hospitalized due to a recent diagnosis of acute lymphoblastic leukemia. As a consequence of induction chemotherapy (CALGB 10403 scheme), she developed severe neutropenia (0.04 10^3/ul). On day 6 of chemotherapy, she complained of epigastric pain, fever, coffee ground emesis, and melena.

Coupling cell proliferation rates to the duration of recruitment controls final size of the Drosophila wing.

Organ growth driven by cell proliferation is an exponential process. As a result, even small variations in proliferation rates, when integrated over a relatively long developmental time, will lead to large differences in size. How organs robustly control their final size despite perturbations in cell proliferation rates throughout development is a long-standing question in biology. Using a mathematical model, we show that in the developing wing of the fruit fly, Drosophila melanogaster, variations in proliferation rates of wing-committed cells are inversely proportional to the duration of cell recruitment, a differentiation process in which a population of undifferentiated cells adopt the wing fate by expressing the selector gene, vestigial. A time-course experiment shows that vestigial-expressing cells increase exponentially while recruitment takes place, but slows down when recruitable cells start to vanish, suggesting that undifferentiated cells may be driving proliferation of wing-committed cells. When this observation is incorporated in our model, we show that the duration of cell recruitment robustly determines a final wing size even when cell proliferation rates of wing-committed cells are perturbed. Finally, we show that this control mechanism fails when perturbations in proliferation rates affect both wing-committed and recruitable cells, providing an experimentally testable hypothesis of our model.

SCA-Safe Implementation of Modified SaMAL2R Algorithm in FPGA.

Cryptographic algorithms (RSA, DSA, and ECC) use modular exponentiation as part of the principal operation. However, Non-profiled Side Channel Attacks such as Simple Power Analysis and Differential Power Analysis compromise cryptographic algorithms that use such operation. In this work, we present a modification of a modular exponentiation algorithm implemented in programmable devices, such as the Field Programmable Gate Array, for which we use Virtex-6 and Artix-7 evaluation boards. It is shown that this proposal is not vulnerable to the attacks mentioned previously. Further, a comparison was made with other related works, which use the same family of FPGAs. These comparisons show that this proposal not only defeats physical attack but also reduces the number of resources. For instance, the present work reduces the Look-Up Tables by 3550 and the number of Flip-Flops was decreased by 62,583 compared with other works. Besides, the number of memory blocks used is zero in the present work, in contrast with others that use a large number of blocks. Finally, the clock cycles (latency) are compared in different programmable devices to perform operations.

Live fish learn to anticipate the movement of a fish-like robot.

The ability of an individual to predict the outcome of the actions of others and to change their own behavior adaptively is called anticipation. There are many examples from mammalian species-including humans-that show anticipatory abilities in a social context, however, it is not clear to what extent fishes can anticipate the actions of their interaction partners or what the underlying mechanisms are for that anticipation. To answer these questions, we let live guppies (Poecilia reticulata) interact repeatedly with an open-loop (noninteractive) biomimetic robot that has previously been shown to be an accepted conspecific. The robot always performed the same zigzag trajectory in the experimental tank that ended in one of the corners, giving the live fish the opportunity to learn both the location of the final destination as well as the specific turning movement of the robot over three consecutive trials. The live fish's reactions were categorized into a global anticipation, which we defined as relative time to reach the robot's final corner, and a local anticipation which was the relative time and location of the live fish's turns relative to robofish turns. As a proxy for global anticipation, we found that live fish in the last trial reached the robot's destination corner significantly earlier than the robot. Overall, more than 50% of all fish arrived at the destination before the robot. This is more than a random walk model would predict and significantly more compared to all other equidistant, yet unvisited, corners. As a proxy for local anticipation, we found fish change their turning behavior in response to the robot over the course of the trials. Initially, the fish would turn after the robot, which was reversed in the end, as they began to turn slightly before the robot in the final trial. Our results indicate that live fish are able to anticipate predictably behaving social partners both in regard to final movement locations as well as movement dynamics. Given that fish have been found to exhibit consistent behavioral differences, anticipation in fish could have evolved as a mechanism to adapt to different social interaction partners.

Addressing Health Equity and Racism Through a Hispanic Psychiatry Fellowship.

The scarcity of bilingual psychiatrists, as well as appropriate mental health services for populations with limited English proficiency, has led to inequitable health outcomes. A fellowship program was developed, which draws from a clinical model staffed by bilingual (Spanish-English) professionals from racial-ethnic minority groups, to address access to care and the structural determinants of health. This new Hispanic Psychiatry Fellowship focuses on health inequality and racism in policy and leadership, clinical care for Spanish-speaking patients, cultural psychiatry, recovery, forensics, substance use, and education. This column describes the program's development, first 2 years of implementation, and feasibility indicators for use in creating similar programs.

Gene expression profiling of inflammatory cytokines in esophageal biopsies of different phenotypes of gastroesophageal reflux disease: a cross-sectional study.

BACKGROUND: The clinical endoscopic phenotypes of gastroesophageal reflux disease (GERD) are classified as Barrett's esophagus (BE), erosive esophagitis (EE) and non-erosive gastroesophageal reflux disease (NERD). NERD is subclassified as abnormal acid exposure (AAE) and normal acid exposure (NAE) based on pH monitoring study results. The aim of this study was to characterize genes involved in the pathophysiology and immune response of GERD. METHODS: This is an observational and cross-sectional study. All patients with BE, EE, AAE, and NAE and a control group were subjected to superior endoscopy (with biopsies of esophageal mucosa). Relative mRNA quantification of cytokine and target genes was conducted by quantitative Polymerase Chain Reaction (RT-qPCR). Changes in the expression of genes associated with inflammation were assessed for each disease phenotype. Statistical analysis of differential gene expression was performed using the Mann-Whitney U non-parametric test. A p value < 0.05 was considered significant. RESULTS: A total of 82 patients were included and were divided into the following groups: Group BE, 16 (19.51%); Group EE, 23 (28.04%); Group AAE, 13 (15.86%); NAE 13 (15.86%); and Control Group, 17 (20.73%). Compared with the control group, patients with BE exhibited increased IL-8 expression (p < 0.05) and increased levels of IL-10, MMP-3, and MMP-9. Patients with EE exhibited increased levels of IL-1B, IL-6 and IL-10 (p < 0.05), and patients with AAE exhibited increased expression of IL-1B, IL-6, IFN-γ and TNF-α (p < 0.05). AAE exhibited increased IL-1B and TNF-α expression compared with NAE (p < 0.05). CONCLUSION: This study demonstrates the differential expression of mediators of inflammation in the esophageal mucosa of patients with different GERD endoscopic phenotypes. IL-1B and TNF-α could be useful to differentially diagnose AAE and NAE in the non-erosive phenotype using endoscopic biopsies.

Can topical epinephrine application to the papilla prevent pancreatitis after endoscopic retrograde cholangiopancreatography? Results from a double blind, multicentre, placebo controlled, randomised clinical trial.

BACKGROUND AND STUDY AIMS: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. PATIENTS AND METHODS: This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. RESULTS: Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). CONCLUSION: Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. TRIAL REGISTRATION NUMBER: This study was registered with ClinicalTrials.gov (NCT02959112).

Inducing your neighbors to become like you: cell recruitment in developmental patterning and growth.

Cell differentiation, proliferation, and morphogenesis are generally driven by instructive signals that are sent and interpreted by adjacent tissues, a process known as induction. Cell recruitment is a particular case of induction in which differentiated cells produce a signal that drives adjacent cells to differentiate into the same type as the inducers. Once recruited, these new cells may become inducers to continue the recruitment process, closing a feed-forward loop that propagates the growth of a specific cell-type population. So far, little attention has been given to cell recruitment as a developmental mechanism. Here, we review the components of cell recruitment and discuss its contribution to development in three different examples: the Drosophila wing, the vertebrate inner ear, and the mammalian thyroid gland. Finally, we posit some open questions about the role of cell recruitment in organ patterning and growth.

A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions

INTRODUCTION: the aim of this study was to determine the risk factors for rebleeding following device-assisted enteroscopy therapy of small bowel vascular lesions. METHODS: this is a systematic review and meta-analysis. A literature search was performed from January 2003 to October 2019. All studies reporting on at least one risk factor for bleeding recurrence after endoscopic therapy of small bowel vascular lesions were included. A meta-analysis of those risk factors reported in at least three studies was performed to assess their association with rebleeding. The OR and 95 % CI were used for binary outcome data. Heterogeneity analysis was performed using the Tau and I2 index. If I2 > 20 %, potential sources of heterogeneity were identified by sensitivity analyses and a random-effect model was used. RESULTS: the search identified a total of 572 articles and 35 full-text records were assessed for eligibility after screening. Finally, eight studies that included 548 patients were selected. The overall median rebleeding rate was 38.5 % (range: 10.9-53.3 %) with a median follow-up of 24.5 months. Female sex (OR: 1.96, 95 % CI: 1.14-3.37, p = 0.01, I2 = 0 %), Osler-Weber syndrome (OR: 4.35, 95 % CI: 1.22-15.45, p = 0.02, I2 = 0 %) and cardiac disease (OR: 1.89, 95 % CI: 1.12-2.97, p = 0.005, I2: 0 %) were associated with rebleeding. According to the sensitivity analysis, overt bleeding (OR: 2.13, 95 % CI: 1.22-3.70, p = 0.007, I2 = 0 %), multiple lesions (OR: 4.57, 95 % CI: 2.04-10.22, p < 0.001, I2 = 0 %) and liver cirrhosis (OR: 2.61, 95 % CI: 1.11-6.13, p = 0.03, I2 = 0 %) were also predictors for rebleeding. CONCLUSIONS: patient characteristics and comorbidities should be considered for follow-up patient management after effective device-assisted endoscopic therapy, as they can predict rebleeding

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Endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy in patients with surgically altered gastrointestinal anatomy

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) allows a diagnostic and therapeutic evaluation of pancreatobiliary diseases. However, the procedure in patients with surgically altered gastrointestinal anatomy represents a technical challenge. OBJECTIVE: to report the diagnostic and therapeutic outcome of device-assisted enteroscopy (DAE) ERCP in patients with a surgically altered gastrointestinal anatomy. METHODS: a prospective cohort of patients with a history of surgically altered gastrointestinal anatomy undergoing DAE-ERCP in a referral center was used. A double-balloon enteroscope was used to reach the papillary area or the bilio-enteric anastomosis. The clinical and endoscopic characteristics, and technical, diagnostic and therapeutic success were described. Clinical and endoscopic differences were evaluated according to diagnostic success, as well as the biochemical response in those patients with therapeutic success. RESULTS: ninety-six procedures were included in the study in 75 patients. Roux-en-Y hepaticojejunostomy (RYHJ) was the main surgical anatomy (82.3%) and cholangitis was the main indication for ERCP (49%). Diagnostic success was obtained in 69.8% of the participants. Of these, therapeutic success was obtained in 83.6% (overall success 58.3%). Cases with a diagnostic success had a higher frequency of cholangiography compared to those without diagnostic success (94% vs 0%, p < 0.001), as well as a lower probability of a failed cannulation (1.5% vs 100%, p < 0.001). A significant improvement was observed in patients with a therapeutic success in bilirubin, transaminases and alkaline phosphatase levels (p < 0.05). CONCLUSIONS: ERCP by means of double-balloon enteroscopy is a useful technique in patients with a surgically altered gastrointestinal anatomy, in whom access to the bile duct is required. However, these procedures are very challenging and diagnostic and therapeutic success where achieved in up to 60% of cases

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A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions.

INTRODUCTION: the aim of this study was to determine the risk factors for rebleeding following device-assisted enteroscopy therapy of small bowel vascular lesions. METHODS: this is a systematic review and meta-analysis. A literature search was performed from January 2003 to October 2019. All studies reporting on at least one risk factor for bleeding recurrence after endoscopic therapy of small bowel vascular lesions were included. A meta-analysis of those risk factors reported in at least three studies was performed to assess their association with rebleeding. The OR and 95 % CI were used for binary outcome data. Heterogeneity analysis was performed using the Tau and I2 index. If I2 > 20 %, potential sources of heterogeneity were identified by sensitivity analyses and a random-effect model was used. RESULTS: the search identified a total of 572 articles and 35 full-text records were assessed for eligibility after screening. Finally, eight studies that included 548 patients were selected. The overall median rebleeding rate was 38.5 % (range: 10.9-53.3 %) with a median follow-up of 24.5 months. Female sex (OR: 1.96, 95 % CI: 1.14-3.37, p = 0.01, I2 = 0 %), Osler-Weber syndrome (OR: 4.35, 95 % CI: 1.22-15.45, p = 0.02, I2 = 0 %) and cardiac disease (OR: 1.89, 95 % CI: 1.12-2.97, p = 0.005, I2: 0 %) were associated with rebleeding. According to the sensitivity analysis, overt bleeding (OR: 2.13, 95 % CI: 1.22-3.70, p = 0.007, I2 = 0 %), multiple lesions (OR: 4.57, 95 % CI: 2.04-10.22, p < 0.001, I2 = 0 %) and liver cirrhosis (OR: 2.61, 95 % CI: 1.11-6.13, p = 0.03, I2 = 0 %) were also predictors for rebleeding. CONCLUSIONS: patient characteristics and comorbidities should be considered for follow-up patient management after effective device-assisted endoscopic therapy, as they can predict rebleeding.