BACKGROUND AND PURPOSE:

Overuse of CT-based cerebrovascular imaging in the emergency department and inpatient settings, notably CTA of the head and neck for minor and nonfocal neurologic presentations, stresses imaging services and exposes patients to radiation and contrast. Furthermore, such CT-based imaging is often insufficient for definitive diagnosis, necessitating additional MR imaging. Recent advances in fast MRI may allow timely assessment and a reduced need for head and neck CTA in select populations.

BACKGROUND AND PURPOSE:

Mechanical thrombectomy is a fundamental intervention for acute ischemic stroke treatment. While conventional techniques are effective, cyclic aspiration (CyA) shows potential for better recanalization rates. We aim to investigate factors affecting CyA and compare them with static aspiration (StA).

BACKGROUND AND PURPOSE:

Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement.

BACKGROUND AND PURPOSE:

Reocclusion after treatment is a concern in endovascular therapy for isolated intracranial atherothrombotic stroke-related large-vessel occlusion (AT-LVO). However, the optimal endovascular therapy technique for AT-LVO has not yet been investigated. This study evaluated the optimal endovascular therapy technique for AT-LVO in a real-world setting.

BACKGROUND AND PURPOSE:

Vertebrobasilar artery stent placement (VBS) is potentially effective in preventing recurrent posterior circulation strokes; however, the incidences of in-stent restenosis and stented-territory ischemic events based on the location of stent placement have rarely been investigated. We aimed to investigate the characteristics and prognosis of VBS between intracranial and extracranial.

BACKGROUND AND PURPOSE:

Alterations of the basilar artery (BA) anatomy have been suggested as a possible MRA feature of Fabry disease (FD). Nonetheless, no information about their clinical or pathophysiologic correlates is available, limiting our comprehension of the real impact of vessel remodeling in FD.

BACKGROUND AND PURPOSE:

Incidental findings on brain MRI and variations of the circle of Willis (CoW) are relatively common among the general population. Ethnic differences have been described before, but few studies have explored the prevalence of incidental intracranial cerebrovascular findings and CoW variants in the setting of a single multiethnic cohort. The purpose of this investigation was to describe both incidental cerebrovascular findings and the morphology of the CoW on high-resolution 3T TOF-MRA in a UK tri-ethnic population-based cohort and to present updated prevalence estimates and morphologic reference values.

BACKGROUND AND PURPOSE:

Intracranial vessel wall imaging is technically challenging to implement, given the simultaneous requirements of high spatial resolution, excellent blood and CSF signal suppression, and clinically acceptable gradient times. Herein, we present our preliminary findings on the evaluation of a deep learning–optimized sequence using T1-weighted imaging.

BACKGROUND AND PURPOSE:

Recently, artificial intelligence tools have been deployed with increasing speed in educational and clinical settings. However, the use of artificial intelligence by trainees across different levels of experience has not been well-studied. This study investigates the impact of artificial intelligence assistance on the diagnostic accuracy for intracranial hemorrhage and large-vessel occlusion by medical students and resident trainees.

SUMMARY:

Vascular inflammation is widely recognized as an important factor in the atherosclerotic process, particularly in terms of plaque development and progression. Conventional tests, such as measuring circulating inflammatory biomarkers, lack the precision to identify specific areas of vascular inflammation. In this context, noninvasive imaging modalities can detect perivascular fat changes, serving as a marker of vascular inflammation. This review aims to provide a comprehensive overview of the key concepts related to perivascular carotid fat and its pathophysiology. Additionally, we examine the existing literature on the association of pericarotid fat with features of plaque vulnerability and cerebrovascular events. Finally, we scrutinize the advantages and limitations of the noninvasive assessment of pericarotid fat.

Dihydropyrimidinase (DHP) deficiency is an autosomal recessive metabolic disorder caused by biallelic pathogenic variants of DPYS. Patients with DHP deficiency exhibit a broad spectrum of phenotypes, ranging from severe neurological and gastrointestinal involvement to cases with no apparent symptoms. The biochemical diagnosis of DHP deficiency is based on the detection of a significant amount of dihydropyrimidines in urine, plasma, and cerebrospinal fluid samples. Molecular genetic testing, specifically the identification of biallelic pathogenic variants in DPYS, has proven instrumental in confirming the diagnosis and facilitating family studies. This case study documents the diagnostic journey of an 18-yr-old patient with DHP deficiency, highlighting features at the severe end of the clinical spectrum. Notably, our patient exhibited previously unreported skeletal features that positively responded to bisphosphonate treatment, contributing valuable insights to the clinical characterization of DHP deficiency. Additionally, a novel DPYS variant was identified and confirmed pathogenicity through metabolic testing, further expanding the variant spectrum of the gene. Our case emphasizes the importance of a comprehensive diagnostic approach using genetic sequencing and metabolic testing for accurate diagnosis.

The potential for more than one distinct hematolymphoid neoplasm to arise from a common mutated stem or precursor cell has been proposed based on findings in primary human malignancies. Particularly, angioimmunoblastic T-cell lymphoma (AITL), which shares a somatic mutation profile in common with other hematopoietic malignancies, has been reported to occur alongside myeloid neoplasms or clonal B-cell proliferations, with identical mutations occurring in more than one cell lineage. Here we report such a case of an elderly woman who was diagnosed over a period of 8 years with diffuse large B-cell lymphoma, polycythemia vera, and AITL, each harboring identical somatic mutations in multiple genes. Overall, at least five identical nucleotide mutations were shared across multiple specimens, with two identical mutations co-occurring at variable variant allele frequencies in all three specimen types. These findings lend credence to the theory that a common mutated stem cell could give rise to multiple neoplasms through parallel hematopoietic differentiation pathways.

Although the progressive histologic steps leading to endometrial cancer (EndoCA), the most common female reproductive tract malignancy, from endometrial hyperplasia are well-established, the molecular changes accompanying this malignant transformation in a single patient have never been described. We had the unique opportunity to investigate the paired histologic and molecular features associated with the 12-yr development of EndoCA in a postmenopausal female who could not undergo hysterectomy and instead underwent progesterone treatment. Using a specially designed 58-gene next-generation sequencing panel, we analyzed a total of 10 sequential biopsy samples collected over this time frame. A total of eight pathogenic/likely pathogenic mutations in seven genes, APC, ARID1A, CTNNB1, CDKN2A, KRAS, PTEN, and TP53, were identified. A PTEN nonsense mutation p.W111* was present in all samples analyzed except histologically normal endometrium. Apart from this PTEN mutation, the only other recurrent mutation was KRAS G12D, which was present in six biopsy samplings, including histologically normal tissue obtained at the patient's first visit but not detectable in the cancer. The PTEN p.W111* mutant allele fractions were lowest in benign, inactive endometrial glands (0.7%), highest in adenocarcinoma (36.9%), and, notably, were always markedly reduced following progesterone treatment. To our knowledge, this report provides the first molecular characterization of EndoCA development in a single patient. A single PTEN mutation was present throughout the 12 years of cancer development. Importantly, and with potential significance toward medical and nonsurgical management of EndoCA, progesterone treatments were consistently noted to markedly decrease PTEN mutant allele fractions to precancerous levels.

Metastatic porocarcinomas (PCs) are vanishingly rare, highly aggressive skin adnexal tumors with mortality rates exceeding 70%. Their rarity has precluded the understanding of their disease pathogenesis, let alone the conduct of clinical trials to evaluate treatment strategies. There are no effective agents for unresectable PCs. Here, we successfully demonstrate how functional precision medicine was implemented in the clinic for a metastatic PC with no known systemic treatment options. Comprehensive genomic profiling of the tumor specimen did not yield any actionable genomic aberrations. However, ex vivo drug testing predicted pazopanib efficacy, and indeed, administration of pazopanib elicited remarkable clinicoradiological response. Pazopanib and its class of drugs should be evaluated for efficacy in other cases of PC, and the rationale for efficacy should be determined when PC tumor models become available. A functional precision medicine approach could be useful to derive effective treatment options for rare cancers.

Inositol 1,4,5-triphosphate receptor type 1 (ITPR1) is an endoplasmic reticulum–bound intracellular inositol triphosphate receptor involved in the regulation of intracellular calcium. Pathogenic variants in ITPR1 are associated with spinocerebellar ataxia (SCA) types 15/16 and 29 and have recently been implicated in a facial microsomia syndrome. In this report, we present a family with three affected individuals found to have a heterozygous missense c.800C > T (predicted p.Thr267Met) who present clinically with a SCA29-like syndrome. All three individuals presented with varying degrees of ataxia, developmental delay, and apparent intellectual disability, as well as craniofacial involvement—an uncommon finding in patients with SCA29. The variant was identified using clinical exome sequencing and validated with Sanger sequencing. It is presumed to be inherited via parental germline mosaicism. We present our findings to provide additional evidence for germline mosaic inheritance of SCA29, as well as to expand the clinical phenotype of the syndrome.

We identified a de novo heterozygous transient receptor potential cation channel subfamily M (melastatin) member 3 (TRPM3) missense variant, p.(Asn1126Asp), in a patient with developmental delay and manifestations of cerebral palsy (CP) using phenotype-driven prioritization analysis of whole-genome sequencing data with Exomiser. The variant is localized in the functionally important ion transport domain of the TRPM3 protein and predicted to impact the protein structure. Our report adds TRPM3 to the list of Mendelian disease–associated genes that can be associated with CP and provides further evidence for the pathogenicity of the variant p.(Asn1126Asp).

Alveolar capillary dysplasia (ACD) is a fatal disorder that typically presents in the neonatal period with refractory hypoxemia and pulmonary hypertension. Lung biopsy is traditionally required to establish the diagnosis. We report a 22-mo-old male who presented with anemia, severe pulmonary hypertension, and right heart failure. He had a complicated hospital course resulting in cardiac arrest and requirement for extracorporeal membrane oxygenation. Computed tomography of the chest showed a heterogenous pattern of interlobular septal thickening and pulmonary edema. The etiology of his condition was unknown, lung biopsy was contraindicated because of his medical fragility, and discussions were held to move to palliative care. Rapid whole-genome sequencing (rWGS) was performed. In 2 d it resulted, revealing a novel FOXF1 gene pathogenic variant that led to the presumptive diagnosis of atypical ACD. Cases of atypical ACD have been reported with survival in patients using medical therapy or lung transplantation. Based on the rWGS diagnosis and more favorable potential of atypical ACD, aggressive medical treatment was pursued. The patient was discharged home after 67 d in the hospital; he is currently doing well more than 30 mo after his initial presentation with only one subsequent hospitalization and no requirement for lung transplantation. Our case reveals the potential for use of rWGS in a critically ill child in which the diagnosis is unknown. rWGS and other advanced genetic tests can guide clinical management and expand our understanding of atypical ACD and other conditions.

Here, we highlight the case of a 31-yr-old man who had clinical features of primary hypertrophic osteoarthropathy (PHOAR) and harbored a homozygous variant (c.38C > A, p.Ala13Glu) in the HPGD gene, as indicated by whole-exome sequencing (WES). This variant has been previously classified by our laboratory as a variant of uncertain significance (VUS). However, another patient with the same phenotype and the same homozygous variant in HPGD was subsequently reported. In reassessing the variant, the absence of this variant in the gnomAD population database, supporting computational predictions, observation in homozygosity in two probands, and specificity of the phenotype for HPGD, all provide sufficient evidence to reclassify the HPGD c.38C > A, p.Ala13Glu variant as likely pathogenic.

T-lymphoblastic lymphoma (T-LLy) is the most common lymphoblastic lymphoma in children and often presents with a mediastinal mass. Lymphomatous suprarenal masses are possible but rare. Here, we discuss the case of a previously healthy 3-yr-old male who presented with mediastinal T-LLy with bilateral suprarenal masses. Following initial treatment, surgical biopsy of persisting adrenal masses revealed bilateral neuroblastoma (NBL). A clinical genetics panel for germline cancer predisposition did not identify any pathogenic variants. Combination large panel (864 genes) profiling analysis in the context of a precision oncology study revealed two novel likely pathogenic heterozygous variants: SMARCA4 c.1420-1G > T p.? and EZH2 c.1943G > C p.(Ile631Phefs*44). Somatic analysis revealed potential second hits/somatic variants in EZH2 (in the T-LLy) and a segmental loss in Chromosome 19p encompassing SMARCA4 (in the NBL). Synchronous cancers, especially at a young age, warrant genetic evaluation for cancer predisposition; enrollment in a precision oncology program assessing germline and tumor DNA can fulfill that purpose, particularly when standard first-line genetic testing is negative and in the setting of tumors that are not classic for common cancer predisposition syndromes.

Sleep is a fundamental feature of life for virtually all multicellular animals, but many questions remain about how sleep is regulated by circadian rhythms, homeostatic sleep drive that builds up with wakefulness, and modifying factors such as hunger or social interactions, as well as about the biological functions of sleep. Substantial headway has been made in the study of both circadian rhythms and sleep in the fruit fly Drosophila melanogaster, much of it through studies of individual fly activity using Drosophila activity monitors (DAMs). Here, we describe approaches for the activation of specific neurons of interest using optogenetics (involving genetic modifications that allow for light-based neuronal activation) and thermogenetics (involving genetic modifications that allow for temperature-based neuronal activation) so that researchers can evaluate the roles of those neurons in controlling rest and activity behavior. In this protocol, we describe how to set up a rig for simultaneous optogenetic or thermogenetic stimulation and activity monitoring for analysis of sleep and circadian rhythms in Drosophila, how to raise appropriate flies, and how to perform the experiment. This protocol will allow researchers to assess the causative role in the regulation of sleep and activity rhythms of any genetically tractable subset of cells.

Sleep is important for survival, and the need for sleep is conserved across species. In the past two decades, the fruit fly Drosophila melanogaster has emerged as a promising system in which to study the genetic, neural, and physiological bases of sleep. Through significant advances in our understanding of the regulation of sleep in flies, the field is poised to address several open questions about sleep, such as how the need for sleep is encoded, how molecular regulators of sleep are situated within brain networks, and what the functions of sleep are. Here, we describe key findings, open questions, and commonly used methods that have been used to inform existing theories and develop new ways of thinking about the function, regulation, and adaptability of sleep behavior.

BackgroundDuring the COVID-19 pandemic, global trends of reduced healthcare-seeking behaviour were observed. This raises concerns about the consequences of healthcare avoidance for population health.AimTo determine the association between healthcare avoidance during the early stages of the COVID-19 pandemic and all-cause mortality.Design and settingThis was a 32-month follow-up within the population-based Rotterdam Study, after sending a COVID-19 questionnaire at the onset of the pandemic in April 2020 to all communty dwelling participants (n = 6241/8732, response rate 71.5%).MethodCox proportional hazards models assessed the risk of all-cause mortality among respondents who avoided health care because of the COVID-19 pandemic. Mortality status was collected through municipality registries and medical records.ResultsOf 5656 respondents, one-fifth avoided health care because of the COVID-19 pandemic (n = 1143). Compared with non-avoiders, those who avoided health care more often reported symptoms of depression (n = 357, 31.2% versus n = 554, 12.3%) and anxiety (n = 340, 29.7% versus n = 549, 12.2%), and more often rated their health as poor to fair (n = 336, 29.4% versus n = 457, 10.1%) . Those who avoided health care had an increased adjusted risk of all-cause mortality (hazard ratio [HR] 1.30, 95% confidence interval [CI] = 1.01 to 1.67), which remained nearly identical after adjustment for history of any non-communicable disease (HR 1.20, 95% CI = 0.93 to 1.54). However, this association attenuated after additional adjustment for mental and physical self-perceived health factors (HR 0.93, 95% CI = 0.71 to 1.20).ConclusionThis study found an increased risk of all-cause mortality among individuals who avoided health care during COVID-19. These individuals were characterised by poor mental and physical self-perceived health. Therefore, interventions should be targeted to these vulnerable individuals to safeguard their access to primary and specialist care to limit health disparities, inside and beyond healthcare crises.

PURPOSE

Meeting scholarly activity requirements continues to be a challenge in many family medicine (FM) residency programs. Studies comprehensively describing FM resident scholarship have been limited. We sought to identify institutional factors associated with increased scholarly output and meeting requirements of the Accreditation Council for Graduate Medical Education (ACGME).

PURPOSE

We undertook a trial to test the efficacy of a technology-assisted health coaching intervention for weight management, called Goals for Eating and Moving (GEM), within primary care.

Mammalian astrocytes have regional roles within the brain parenchyma. Indeed, the notion that astrocytes are molecularly heterogeneous could help explain how the central nervous system (CNS) retains embryonic positional information through development into specialized regions into adulthood. A growing body of evidence supports the concept of morphological and molecular differences between astrocytes in different brain regions, which might relate to their derivation from regionally patterned radial glia and/or local neuron inductive cues. Here, we review evidence for regionally encoded functions of astrocytes to provide an integrated concept on lineage origins and heterogeneity to understand regional brain organization, as well as emerging technologies to identify and further investigate novel roles for astrocytes.

α-Synuclein (AS) is a small presynaptic protein that is genetically, biochemically, and neuropathologically linked to Parkinson's disease (PD) and related synucleinopathies. We present here a review of the topic of this relationship, focusing on more recent knowledge. In particular, we review the genetic evidence linking AS to familial and sporadic PD, including a number of recently identified point mutations in the SNCA gene. We briefly go over the relevant neuropathological findings, stressing the evidence indicating a correlation between aberrant AS deposition and nervous system dysfunction. We analyze the structural characteristics of the protein, in relation to both its physiologic and pathological conformations, with particular emphasis on posttranslational modifications, aggregation properties, and secreted forms. We review the interrelationship of AS with various cellular compartments and functions, with particular focus on the synapse and protein degradation systems. We finally go over the recent exciting data indicating that AS can provide the basis for novel robust biomarkers in the field of synucleinopathies, while at the same time results from the first clinical trials specifically targeting AS are being reported.

Chronic pulmonary aspergillosis has a range of manifestations from indolent nodules to semi-invasive infection. Patients may be asymptomatic or have chronic symptoms such as cough and weight loss or present with life-threatening haemoptysis. The physician can choose from a range of available therapies including medical therapy with antifungals, minimally invasive therapy with intracavitary antifungal therapy and surgery involving open thoracotomy or video-assisted thoracoscopic surgery. The patients with the most severe forms of pulmonary infection may not be surgical candidates due to their underlying pulmonary condition. The management of haemoptysis can include tranexamic acid, bronchial artery embolisation, antifungals or surgery. There are few controlled studies to inform clinicians managing complex cases, so a multidisciplinary approach may be helpful.

COPD is a heterogeneous condition, with tobacco smoking being the main environmental risk factor. The presence of type 2 (T2) inflammation is a well-recognised feature of asthma; however, it is now apparent that a subset of COPD patients also displays evidence of T2 inflammation with respect to elevated eosinophil counts and altered gene and protein expression of several T2 inflammatory mediators. T2 inflammatory mediators represent an attractive therapeutic target in both COPD and asthma; however, the efficacy of pharmaceutical interventions varies between diseases. Furthermore, the nature of some shared clinical features also differs. We provide a narrative review of differences in the nature of T2 inflammation between COPD and asthma, which may partly explain phenotypic differences between diseases. We focus on evidence from studies of pulmonary histopathology, sputum and epithelial gene and protein expression, and response to pharmacological interventions targeted at T2 inflammation.

The deadline to claim part of the $15 million Cash App settlement is November 18. Here's what to know.

Robert Eggers' re-imagining of the legendary vampire has his fangs out for prey in a very unusual manner.

The two robots, working alone and far apart from one another, are struggling on their respective treks along the Red Planet's rough terrain.

Tim Miller hopes Amazon's anthology series will help viewers appreciate the "blood, sweat, and tears" Firewalk Studios put into the scrapped game.

The leak caught national intelligence officials by surprise and led to an embarrassing Air Force Inspector General investigation.

Cassian's on a new mission to steal a familiar ship in the next season of his self-titled Star Wars show.

This is not a joke, the subscription to ExpressVPN is at an unprecedented price. We'll tell you everything you need to know so you don't miss out on its Black Friday offer.

Five years on from its incredible debut, The Mandalorian has come to embody a lot of the issues facing Star Wars in its uncertain current moment.

Netflix's mega-violent mega-hit series returns December 26.

Deepfakes can be close to indistinguishable from authentic video, and are now being used to perpetrate gender based abuse.

The post Deepfakes and gender based violence appeared first on rabble.ca.

At least 231 people were killed and hundreds more wounded after a massive truck bomb on Saturday struck Somalia’s capital city of Mogadishu.

The Somali government has blamed the al-Qaida-linked militant group al-Shabab for the attack, and called it the deadliest ever to hit the nation.

The blast took place outside the Safari Hotel, where rescue workers dug through the rubble of collapsed buildings overnight in search of survivors. Witnesses described a devastating scene with large-scale carnage, as doctors worked feverishly to attend to the dead and injured, many badly burned.

“The hospital is overwhelmed by both dead and wounded,” Dr. Mohamed Yusuf, the director of Medina hospital located near the blast, told the Associated Press. “We also received people whose limbs were cut away by the bomb. This is really horrendous, unlike any other time in the past.”

Photos and videos of the bombing, which took place on a busy street near a section of the city housing foreign embassies, showed collapsed walls, twisted metal, and sporadic fires spewing smoke. The Qatari government said its embassy was “severely damaged” in the strike.

There should be an embedded item here. Please visit the original post to view it.

Family members searched through the wreckage and waited at local hospitals with the hopes of finding relatives who survived the bombing.

Somali President Mohamed Abdullahi Mohamed announced three days of mourning. The attacks received international condemnation, including from the United States.

The post Hundreds dead after massive truck bomb strikes Mogadishu appeared first on PBS NewsHour.

Watch Video | Listen to the Audio

JUDY WOODRUFF: Longstanding rivalries were re-ignited in Iraq today between vital American allies.

Iraqi military forces and militia moved to push Kurdish forces out of the disputed city of Kirkuk in the country’s north.

Lisa Desjardins begins our coverage.

MAN (through interpreter): The commander in chief of the armed forces, Dr. Haider al-Abadi, gave orders to protect the people of Kirkuk and to impose security in the city.

LISA DESJARDINS: After months of simmering tensions, Iraqi federal troops moved to retake the disputed city of Kirkuk from Kurdish forces.

The effort launched before dawn. By midday, Iraqi soldiers, along with state-backed militias, quickly took control of several massive oil fields north of the city. Iraqis also captured Kirkuk’s military airport and various government buildings. They lowered what had been a symbolic Kurdish flag at the governor’s compound.

Journalist Rebecca Collard in Irbil was in Kirkuk this morning.

REBECCA COLLARD, Journalist: You could hear some clashes, some gunfire in the distance, but for the most part, the city seemed more or less abandoned. Now, the Iraqi army, by the end of today, was essentially in control of the whole city and many of the outskirts of Kirkuk.

LISA DESJARDINS: The spokesman for an Iraqi Shiite militia said they achieved all their goals with little resistance.

AHMED AL-ASSADI,  Spokesman for al-Hashed al-Shaabi (through translator): As the troops approached the area, they were confronted by some rebels, who tried to hinder the progress of the advancing units. Our troops returned fire and silenced its source.

LISA DESJARDINS: This comes three weeks after the Kurds held a nonbinding independence referendum that included the disputed province of Kirkuk.

More than 90 percent of the Kurdish region’s residents voted to split from Iraq. The Iraqi federal government, Turkey, Iran and the U.S. all rejected the independence drive.

The multiethnic region of Kirkuk lies just outside of the autonomous Kurdish region in Iraq’s north. Called the country’s oil capital, Kirkuk produces around 500,000 barrels a day.

In 2014, amid the ISIS onslaught across Northern Iraq, the Kurds took control of Kirkuk, as the Iraqi military fled the city. In the three years since, the Kurds, led by their president, Massoud Barzani, sought to cement their hold, despite tensions with the central government.

Today, Kurdish officials accused Iraq of carrying out a major multipronged attack.

MAJ. GEN. AYOUB YUSUF SAID, Peshmerga Commander (through interpreter): I don’t know what is happening exactly, because we have been in this fight since 4:00 in the morning. We have suffered casualties, including martyrs, and now we have withdrawn to this position. Some of the other Kurdish forces have pulled out. They didn’t fire a single shot.

LISA DESJARDINS: While Kurdish forces withdrew from posts south of the city, some residents vowed to die fighting. Thousands of others fled north.

REBECCA COLLARD: For the last few years, the Iraqi forces, these primarily Shia militia, the Hashed Shaabi, and the Kurdish forces have been focused on fighting ISIS. Now that fight is coming to an end, and what the fear is that now these internal division in Iraq are going to become more apparent and possibly more violent.

LISA DESJARDINS: These clashes pit one substantially American-armed military force against another. Both the Kurdish forces and Iraqi government troops are part of the coalition fighting ISIS. The U.S. sought to downplay the fighting, labeling the exchange of gunfire a misunderstanding.

And, in the Rose Garden, President Trump tried to stay neutral.

PRESIDENT DONALD TRUMP: We don’t like the fact that they’re clashing. We’re not taking sides. But we don’t like the fact that they’re clashing.

LISA DESJARDINS: For the PBS NewsHour, I’m Lisa Desjardins.

JUDY WOODRUFF: For more, I’m joined now by Emma Sky. She served as an adviser to General David Petraeus while he was commander of U.S. forces in Iraq from 2007 to 2010, and by Feisal Istrabadi. He’s a former Iraqi ambassador to the United Nations and he helped write Iraq’s interim constitution.

Welcome to both of you.

Let me start with you, Emma Sky.

This has happened so quickly. What exactly has the Iraqi government done?

EMMA SKY, Yale University: The Iraqi government has deployed its forces back up north into Kirkuk.

And since 2003, the Kurds have made it clear that they want to include Kirkuk within their territory in order to proceed with gaining independence, which has always been their goal. But Kirkuk is important to Iraq itself, and no Iraqi prime minister can afford to lose Kirkuk.

So you can see this reaction that has taken place following the referendum on independence, which happened September the 25th, and also included the disputed territories and the city of Kirkuk.

JUDY WOODRUFF: Feisal Istrabadi, what can you add to why the Iraqi government is so set on taking over the city?

FEISAL ISTRABADI, Former Deputy UN Ambassador, Iraq: Well, a couple of reasons.

First, as Emma just said, it is a part of the disputed territories, which are legally and constitutionally under the jurisdiction of the federal government in Baghdad. The KRG expanded into these disputed territories at the time when ISIL was expanding its territory, and then began to take steps to unilaterally declare that these areas were now incorporated into the Kurdistan region, including when it held the referendum that Emma talked about.

It included holding the referendum in these disputed territories. Now, so long as Iraq — so long as we’re talking about a single country, it matters a little less who controls Kirkuk, but once the referendum was held, this gave rise then to the second reason for Baghdad choosing to act now.

As Emma said, Kirkuk is an important oil-producing zone in Iraq. And it is vital for the economic viability of an independent Kurdish state and an important part of the economic viability of the Iraqi state. So there was never going to be a scenario, I think, in which Baghdad would allow a unilateral exercise of control by Kurds to occur over Kirkuk, so long as independence is on the table.

JUDY WOODRUFF: Emma Sky, we heard President Trump say today the U.S. is not taking sides in this.

Is that accurate, that the U.S. isn’t taking sides? What is the U.S. role here?

EMMA SKY: Well, the U.S. has stipulated over and over again that its policy is to support a united Iraq.

So you can see the U.S. has given support to Iraqi security forces, but also to the Kurdish Peshmerga, to fight against ISIS. The U.S. policy for the last few years has really been focused on ISIS and not on the day after ISIS.

But what we’re witnessing at the moment is that different groups are already moving to the day after, which is the power struggle for control of different territories in Iraq.

And Barzani believed that during the fight against ISIS, he became stronger because he got weapons directly from the international community. And, as Feisal said, he was able to extend his control over the disputed territories.

He’s also facing domestic problems within Kurdistan. There are tensions between the different Kurdish groups, and some believe that Barzani has overstayed his term as president.

JUDY WOODRUFF: Which reminds us just how complicated this is, Feisal Istrabadi.

What does the Iraqi central government want here? They’re not going to get rid of the Kurds. What is it that they want?

FEISAL ISTRABADI: Oh, well, I mean, the Kurds of course are a vital part of Iraq. They’re a vital part of the political process, and they have been represented in Baghdad. The president of Iraq is a Kurd and has been since 2005.

I think what needs to occur and I hope what the government of Iraq wants is a negotiated settlement, in which no party dictates terms to the other, but a negotiated settlement.

Look, Irbil has some legitimate agreements with respect to Baghdad. Baghdad has some legitimate agreements with respect to Irbil. I think we need a mediator perhaps or somebody to convene a roundtable — the United States is who I’m thinking of, of course — to address some of those issues.

Most of the issues are, from the Irbil side, economic issues of payments, and from Baghdad’s side, transparency of how much oil Irbil is producing and exporting, which Irbil has never accounted for to Baghdad.

I think if those issues are resolved, perhaps hopefully some of these other issues can at least be delayed for another day. But at the end of the day, neither government — neither the regional government nor the federal government in Baghdad can really tolerate dictation of terms to it by the other side. My hope is that a negotiated settlement obtains.

JUDY WOODRUFF: Emma Sky, where do you see this going from here? Do you see the peace that different sides have worked to hard to create in Iraq unraveling as a result of this?

EMMA SKY: I think there is an opportunity for a deal, and I think the sort of deal that could be negotiated is one that looks at a special status for the city of Kirkuk and negotiated terms for Kurdistan’s separate, whether that be towards confederation or towards independence.

But there needs to be negotiation. There needs to be a look at where should the border between Iraqi Kurdistan and the rest of Iraq actually be, and that requires mediation district by district through those territories.

JUDY WOODRUFF: Well, we know there are other players who are playing an important role here in Iran and Turkey, and this is all very much playing out as we watch, watch it happen in Iraq.

Emma Sky, Feisal Istrabadi, thank you very much.

FEISAL ISTRABADI: Thank you.

EMMA SKY: Thank you.

The post Why a power struggle has broken out over Kirkuk appeared first on PBS NewsHour.