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Summary Though most known for heartburn and regurgitation, gastroesophageal reflux disease (GERD) is attributed to countless atypical, extra-esophageal (EE) manifestations like cough and throat clearing. While GERD has been studied extensively, the relationship between reflux character and symptom manifestation remains poorly understood. The aim of this study was to examine proximal reflux frequency and its relationship with typical or atypical symptoms. 540 (75.1% female, 24.9% male) pH-impedance monitoring studies from the last 3-years were divided by symptom indication and retrospectively reviewed for proximal reflux frequency, total acid exposure time, mean nocturnal baseline impedance, and total reflux episodes in both abnormal and normal, and borderline studies. Baseline characteristics were also collected. Both total reflux events and mean proximal reflux frequency were found to differ significantly between those with typical versus atypical symptoms. Total reflux events [median (IQR)] were 43.5 (24.0–74.0) in typical patients and 35.0 (20.0–57.0) in atypical patients (P-value 0.0369). Proximal reflux frequency [median (IQR)] was 12.0 (4.0–19.0) typical and 7.0 (3.0–17.0) atypical (P-value 0.0348). Results for exclusively abnormal studies also favored typical patients but not significantly. Baseline characteristics and use of gastric acid control did not differ significantly. Proximal reflux frequency was observed to increase among those with typical GERD symptoms. Total acid reflux events were also significantly higher on average with typical patients. Our findings that proximal reflux frequency is reduced in patients with atypical symptoms compared with patients with typical symptoms suggest that proximal reflux exposure may play a significant role in the symptom presentation of typical classic heartburn and regurgitation symptoms. The differential diagnosis for atypical EE symptoms is vast and can be multifactorial. Our results indicate proximal reflux events may contribute to atypical EE symptoms less than previously reported.

Background: Esophageal perforations can occur spontaneously, but most are iatrogenic and related to procedures. The literature reports death rates from 10% to 26%. Our goals were to summarize demographics, comorbidities, managing services, perforation sites, outcomes, and complications of esophageal perforations at a tertiary academic medical center. Methods: This was a retrospective chart review. ICD and CPT codes were used to identify 89 subjects who experienced esophageal perforation from 2008 to 2020. Patients under age 18 were excluded from the study. Results: Patients diagnosed with esophageal perforation averaged 67 years. Perforations affected more males than females. Most perforations were contained and referred from outside hospitals. Thoracic esophageal perforations predominated followed by cervical and abdominal. Iatrogenic causes were identified in 56% of cases. The most common underlying diseases were gastrointestinal, cardiac, and cancer. Most patients were managed by a multidisciplinary team. The most common complication was empyema managed with chest tubes. Conclusions: We report an esophageal perforation mortality rate of 9%. Approximately 1% of perforations directly led to death. All uncontained thoracic perforations were complicated by empyema and managed with chest tubes. We observed more contained versus uncontained perforations, which may have contributed to higher survival rate. Our institution’s multidisciplinary approach to managing perforations potentially contributed to better outcomes and increased survival. Esophageal perforation remains a medical emergency, but perhaps with prompt recognition and interdisciplinary management, outcomes may not be as dreadful as previously reported.

Background Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. Methods A retrospective analysis of all HRM (unweighted sample n=155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n=114) with abnormal AM-IBP and a control group (n=41) with a normal AM-IBP (pressure

We report an improved measurement of the free neutron lifetime $\tau_{n}$ using the UCN$\tau$ apparatus at the Los Alamos Neutron Science Center. We counted a total of approximately $38\times10^{6}$ surviving ultracold neutrons (UCN) after storing in UCN$\tau$'s magneto-gravitational trap over two data acquisition campaigns in 2017 and 2018. We extract $\tau_{n}$ from three blinded, independent analyses by both pairing long and short storage-time runs to find a set of replicate $\tau_{n}$ measurements and by performing a global likelihood fit to all data while self-consistently incorporating the $\beta$-decay lifetime. Both techniques achieve consistent results and find a value $\tau_{n}=877.75\pm0.28_{\text{ stat}}+0.22/-0.16_{\text{ syst}}$~s. With this sensitivity, neutron lifetime experiments now directly address the impact of recent refinements in our understanding of the standard model for neutron decay., Comment: 7 pages, 2 figures, 3 tables

Background and Aim This review investigates the role of gastrointestinal and hepatic manifestations in COVID‐19, particularly with regard to the prevalence of isolated gastrointestinal (GI) symptoms. Methods We searched PubMed, Embase, and Cochrane library for COVID‐19 publications from 1 December 2019 to 18 May 2020. We included any study that reported the presence of GI symptoms in a sample of >5 COVID‐19 patients. Data collection and risk of bias assessment were performed independently by two reviewers. Where ≥3 studies reported data sufficiently similar to allow calculation of a pooled prevalence, we performed random effects meta‐analysis. Results This review included 17 776 COVID‐19 patients from 108 studies. Isolated GI symptoms only occurred in 1% (95% confidence interval [CI] 0–6%) of patients. GI symptoms were reported in 20% (95% CI 15–24%) of patients. The most common were anorexia (21%, 95% CI 15–27%), diarrhea (13%, 95% CI 11–16%), nausea or vomiting (8%, 95% CI 6–11%), and abdominal pain (4%, 95% CI 2–6%). Transaminase elevations were present in 24% (95% CI 17–31%) of patients. Higher prevalence of GI symptoms were reported in studies published after 1st April, with prevalence of diarrhea 16% (95% CI 13–20), nausea or vomiting 12% (95% CI 8–16%), and any GI symptoms 24% (95% CI 18–34%). GI symptoms were associated with severe COVID‐19 disease (odds ratio [OR] 2.1, 95% CI 1.3–3.2), but not mortality (OR 0.90, 95% CI 0.52–1.54). Conclusions Patients with isolated GI symptoms may represent a small but significant portion of COVID‐19 cases. When testing resources are abundant, clinicians should still consider testing patients with isolated GI symptoms or unexplained transaminase elevations for COVID‐19. More recent studies estimate higher overall GI involvement in COVID‐19 than was previously recognized., This review is a systematic review and meta‐analysis to characterize the prevalence of gastrointestinal (GI) and hepatic involvement in COVID‐19 and specifically assess the prevalence of GI symptoms in isolation. This review included 17 776 COVID‐19 patients from 108 studies. Isolated GI symptoms occurred in 1% (95% confidence interval 0–6%) of patients.

Background Combining impedance with pH monitoring improves the detection and characterization of gastro-oesophageal reflux (GOR), yet the two modalities frequently differ in GOR quantification. Ambulatory 24-h pH-impedance monitoring often reveals more significant oesophageal acid exposure than impedance-measured reflux activity in patients with symptomatic gastro-oesophageal reflux disease (GORD). The purpose of this study is to elucidate the discrepancies between these modalities by assessing the predictive accuracy of impedance compared to acid exposure standards. Methods A single-institution, retrospective review of sequential 24-h pH-impedance results of 72 patients with symptomatic GOR off anti-secretory therapy was conducted. Reflux events measured by impedance were stratified by patient position and compared to oesophageal acid exposure time (AET). Oesophageal AET limits for GORD detection were utilized as gold standards to generate serial receiver operator characteristics (ROC) curves to assess the sensitivity and specificity of current impedance GORD detection limits and identify optimized impedance standards based on area under the curve (AUC) analysis. Results Mean total AET time was 10.5% (± 9.9%), and 63.8% of patients had elevated AET. By impedance, median GOR frequency was 43 (IQR 21–68), and 22.2% exceeded conventional GOR frequency limits of normal. ROC curve analysis revealed the current impedance standard of > 73 GOR events has a sensitivity of 32.6% and specificity of 96.5% (AUC 0.74) for GORD detection. By AUC analysis, an impedance threshold of > 41 GOR events is optimal for GORD detection (sensitivity 69.6%, specificity 80.7%, AUC 0.83). Conclusion Conventional impedance standards for abnormal GOR frequency are weakly sensitive for the detection of GORD, providing a possible explanation to discrepancies in AET and impedance interpretation. Lowering impedance-measured GOR frequency limits to > 41 optimizes sensitivity and specificity while increasing congruence between pH and impedance metrics.

International audience; The Ultracold Neutron Asymmetry (UCNA) experiment was designed to measure the β-decay asymmetry parameter, A0, for free neutron decay. In the experiment, polarized ultracold neutrons are transported into a decay trap, and their β-decay electrons are detected with ≈4π acceptance into two detector packages which provide position and energy reconstruction. The experiment also has sensitivity to bn, the Fierz interference term in the neutron β-decay rate. In this work, we determine bn from the energy dependence of A0 using the data taken during the UCNA 2011–2013 run. In addition, we present the same type of analysis using the earlier 2010 A dataset. Motivated by improved statistics and comparable systematic errors compared to the 2010 data-taking run, we present a new bn measurement using the weighted average of our asymmetry dataset fits, to obtain bn=0.066±0.041stat±0.024syst which corresponds to a limit of −0.012

Eosinophilic esophagitis is characterized by dysphagia with esophageal eosinophilia. We sought to determine if intrabolus pressure measurements on high-resolution manometry had any correlation with dysphagia improvement following standard therapy for patients with fibrostenotic eosinophilic esophagitis. Consecutive patients were prospectively enrolled at our swallowing center. Dysphagia scores, esophageal eosinophil counts, endoscopic reference scores, and intrabolus pressure measurements were compared at baseline and following therapy with 8 weeks of a proton-pump inhibitor and serial bougie dilation to a luminal diameter of 17 mm. Five patients were included in the study. The median age was 38 years. The average endoscopic reference score improved from 5.0 to 2.4 (p = 0.007). The mean esophageal diameter improved from 10.8 mm to 17.2 mm (p = 0.001). Dysphagia severity scores improved from a mean value of 34.2 to 10.8 (p = 0.004). Mucosal eosinophilia had no correlation with dysphagia severity. Mean intrabolus pressure improved from 21.8 mmHg to 11 mmHg (p = 0.001). There was strong correlation between a decrease in intrabolus pressure and improvement in dysphagia severity, however, this was not significant (p = 0.108). Intrabolus pressure has strong correlation with dysphagia severity following therapy for fibrostenotic eosinophilic esophagitis. Bougie dilation provides improvement in dysphagia despite persistent mucosal eosinophilia.

Adults and children with eosinophilic esophagitis (EoE) have distinct clinical and endoscopic presentations. Recognition of clinical signs, along with laboratory and endoscopic findings, is critical for the identification of patients with EoE because delay in diagnosis has been associated with esophageal remodeling and stricture formation. Clinical presentation varies considerably between adults and children. This is less due to differences in the disease and more due to patient differences. This article describes the similarities and differences in clinical presentation of children and adults with EoE, including areas of epidemiology, clinical and endoscopic presentation, pathophysiology, and treatment.

Ultracold neutron (UCN) projection imaging is demonstrated using a boron-coated back-illuminated CCD camera and the Los Alamos UCN source. Each neutron is recorded through the capture reactions with 10B. By direct detection at least one of the byproducts α , 7Li and γ (electron recoils) derived from the neutron capture and reduction of thermal noise of the scientific CCD camera, a signal-to-noise improvement on the order of 1 0 4 over the indirect detection has been achieved. Sub-pixel position resolution of a few microns is confirmed for individual UCN events. Projection imaging of test objects shows a spatial resolution less than 100 μ m by an integrated UCN flux one the order of 10 6 cm−2. The bCCD can be used to build UCN detectors with an area on the order of 1 m 2 . The combination of micrometer scale spatial resolution, low readout noise of a few electrons, and large area makes bCCD suitable for quantum science of UCN.

Esophageal perforations are associated with high morbidity and mortality. As opposed to surgical repair, endoscopic closure techniques have emerged over the years as a more minimally invasive approach for management. Our goal is to discuss different modalities for closure. Through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), and esophageal stent placement are well known options for closure. We will also discuss the more recent technique of endoscopic suturing for closure of larger defects as well as prevention of esophageal stent migration. For mediastinal collections associated with perforations, a more novel endoluminal vacuum therapy (EVT) for drainage may be an option. Overall, there are several different endoscopic options that can tailored to the specific features of an esophageal perforation. This review will discuss various techniques with which a gastroenterologist or thoracic surgeon should be familiar.

A new boron-coated CCD camera is described for direct detection of ultracold neutrons (UCN) through the capture reactions $^{10}$B (n,$\alpha$0$\gamma$)$^7$Li (6%) and $^{10}$B(n,$\alpha$1$\gamma$)$^7$Li (94%). The experiments, which extend earlier works using a boron-coated ZnS:Ag scintillator, are based on direct detections of the neutron-capture byproducts in silicon. The high position resolution, energy resolution and particle ID performance of a scientific CCD allows for observation and identification of all the byproducts $\alpha$, $^7$Li and $\gamma$ (electron recoils). A signal-to-noise improvement on the order of 10$^4$ over the indirect method has been achieved. Sub-pixel position resolution of a few microns is demonstrated. The technology can also be used to build UCN detectors with an area on the order of 1 m$^2$. The combination of micrometer scale spatial resolution, few electrons ionization thresholds and large area paves the way to new research avenues including quantum physics of UCN and high-resolution neutron imaging and spectroscopy.

Objectives Percutaneous gastrostomy tube placement is performed in patients requiring long-term enteral nutrition. Although both endoscopic and fluoroscopic techniques may be used, there are inherent risks and potential complications associated with both procedures that are not generally known to referring physicians. The purpose of this study was to compare and contrast indications for placement and procedurally related complications between fluoroscopic and endoscopic gastrostomy tubes techniques at a tertiary care facility. Methods A retrospective cohort study was performed. All consecutive patients with either percutaneous endoscopic (PEG) or percutaneous radiologic (PRG) gastrostomy tube placement between October 2011 and January 2013 were eligible for inclusion. Basic demographic information, American Society of Anesthesiologists score, procedure indication, laboratory data, and use of anticoagulation were recorded. Both direct and indirect procedural complications were documented if they occurred 30 days after gastrostomy tube placement, and were classified and scored based on severity and need for further intervention. Results A total of 297 patients met the inclusion criteria, 150 of whom had gastrostomy tubes placed fluoroscopically and 147 of whom had them placed endoscopically. There was no statistically significant difference in direct complications within the first 30 days (PEG 6.8% vs PRG 8%); however, the type of complication observed varied between the two groups. Although superficial wound infections and buried bumpers were more common in the PEG group, bleeding was more common in the PRG group. Conclusions Placement of gastrostomy tubes either endoscopically or fluoroscopically is relatively safe with similar indications. Although the complication rate between the two groups was not significant, the types of procedural complications observed did vary.

Little is known about the clinical features, radiology and manometry findings, and treatment outcomes of patients with functional and mechanical esophagogastic junction outflow obstruction (EGJOO). Between November 2011 and February 2015, a total of 1443 high-resolution manometries were reviewed and 49 patients (3.4%) met the manometric criteria for EGJOO. Then, we performed a retrospective chart review, collecting data from manometric studies, timed barium esophagram findings (TBEs), endoscopic reports, and clinical records. Twenty-seven patients had functional EGJOO and 22 patients had an anatomic esophageal obstruction. Common causes of anatomic EGJOO included strictures (36% of patients) and hiatal hernias (31% of patients). There were no differences between groups in manometric or radiographic metrics. Each group had increased basal lower esophageal sphincter and intrabolus pressures, compared with individuals without EGJOO, and most patients had abnormal findings on TBE analysis. Two patients with functional EGJOO progressed to type 3 achalasia. We conclude that patients diagnosed with EGJOO based on manometry findings can have anatomic obstruction or functional EGJOO; high-resolution manometry and TBE do not distinguish between disease causes.

Pseudoachalasia, clinically indistinct from achalasia in symptoms and high-resolution manometry findings, differs by a secondary etiology with more than half of the occurrences arising from malignancy. Rarely pseudoachalasia presents after surgeries of the esophagus and gastroesophageal junction. This case offers an additional example of pseudoachalasia after Nissen fundoplication; however, it is unique to the literature by documenting complete manometric progression from normal to pseudoachalasia in a single patient. This case serves to highlight the importance of thorough workups in patients with achalasia symptoms and broadens understanding of this disease process by offering manometric findings in an evolutionary phase.

An elevation of serum inflammatory biomarkers in achalasia patients compared with controls recently was demonstrated. It has not been determined whether the elevation of inflammatory cytokines is unique to achalasia or occurs with other diseases involving the esophagus. The primary aim of our study was to compare the differences in plasma immunological profiles (TNF- α receptor, IL-6, IFN-γ, IL-12, IL-17, IL-22, and IL-23) of patients with achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD). A secondary aim of this study was to classify these same plasma cytokine profiles in the three achalasia subtypes. Methods Plasma from 53 patients with achalasia, 22 with EoE, and 20 with GERD (symptoms plus esophagitis or + reflux study) were analyzed. Exclusion criteria: malignancy, autoimmune condition, immunodeficiency disorder, and treatment with steroids/immune modulating drugs. Cytokine levels were assayed via multiplex enzyme-linked immunosorbent assay (ELISA). Results Our key finding revealed significant elevations in IL- 6 (p = 0.0158) in achalasia patients compared with EoE patients. Overall, plasma inflammatory biomarker patterns were not different in the three subtypes of achalasia. Conclusion There were no differences between the cytokine levels of any of the measured biomarkers between the achalasia and GERD groups suggesting that luminal stasis does increase biomarker levels for any of the cytokines examined in our study. While these results are an early first step towards clarifying some aspects of the pathogenesis of achalasia, they bring about many more questions that require further investigation and expansion. Further investigation with a larger cohort and a broader panel of biomarkers is needed.

EPJ Web of Conferences, 219, ISSN:2100-014X, ISSN:2101-6275, International Workshop on Particle Physics at Neutron Sources (PPNS 2018), Grenoble, France, May 24–26, 2018, ISBN:978-2-7598-9082-8

It has been proposed recently that a previously unobserved neutron decay branch to a dark matter particle (χ) could account for the discrepancy in the neutron lifetime observed in experiments that use two different measurement techniques. One of the possible final states discussed includes a single χ along with an e^+e^− pair. We use data from the UCNA (Ultracold Neutron Asymmetry) experiment to set limits on this decay channel. Coincident electron-like events are detected with ∼4π acceptance using a pair of detectors that observe a volume of stored Ultracold Neutrons (UCNs). The summed kinetic energy (E_(e^+e^−)) from such events is used to set limits, as a function of the χ mass, on the branching fraction for this decay channel. For χ masses consistent with resolving the neutron lifetime discrepancy, we exclude this as the dominant dark matter decay channel at ≫ 5σlevel for 100 keV < E_(e^+e^−) < 644 keV. If the χ + e^+e^− final state is not the only one, we set limits on its branching fraction of 90% confidence level.