Predictors of Morbidity Following Enterostomy Closure in Infants: An American College of Surgeons Pediatric National Surgical Quality Improvement Program Database Analysis.

Optimal timing of enterostomy closure in infants is poorly defined, and clinical practice is based mainly on surgeon preference. This study aims to determine the predictors of morbidity in infants < 365 days old undergoing enterostomy reversal. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP Peds) database was conducted from 2012-2017, including all laparoscopic and open enterostomy reversals in patients < 365 days old. Predictors of overall morbidity were analyzed by bivariate and multivariate logistic regression analysis with statistical significance at P < .05. We identified 2415 cases with an overall morbidity rate of 30.5%. Bivariate analysis identified that younger age, lower weight, prematurity, pulmonary disease, previous cardiac surgery, preoperative nutritional support, preoperative steroids, and preoperative transfusion were associated with overall morbidity for enterostomy closure. On multivariate analysis, prematurity < 30 weeks at birth (odds ratio [OR], 1.49; 95% confidence interval [CI]; 1.07-2.08), pulmonary disease (OR, 1.31; 95% CI, 1.01-1.71), and preoperative nutritional support (OR, 2.46; 95% CI 1.99-3.05) were independently associated with overall morbidity. Age and weight at the time of enterostomy closure were not independently associated with overall morbidity on multivariate analysis. Prematurity < 30 weeks at birth, presence of pulmonary disease, and preoperative need for nutritional support were independent predictors of overall morbidity in patients < 365 days old undergoing enterostomy reversal. Given the high rate of overall morbidity in this population, further research into the matter is warranted.

Nonoperative management of penetrating abdominal solid organ injuries in children.

BACKGROUND: Nonoperative management (NOM) of penetrating solid organ injuries (SOI) has not been well described in the pediatric population. The objective of this study was to characterize the epidemiology, injury patterns, and factors associated with trial and failure of NOM. METHODS: This is a retrospective cohort analysis of the National Trauma Data Bank for the period of 2007-2014. The study population included patients ≤18 y with penetrating injury to the liver, spleen, or kidney. NOM was defined as no operative intervention (exploratory laparotomy or operation involving the liver, spleen, or kidney) < 4 h of emergency department arrival. Failed NOM was defined as operative intervention ≥4 h after emergency department arrival. Multivariate logistic regression explored clinical factors potentially associated with trial and failure of NOM. RESULTS: Of 943,000 pediatric trauma patients included in the National Trauma Data Bank, 3005 (0.32%) met our inclusion criteria. Median age was 17.0 y; 88.8% were male. Gunshot wounds (GSW) accounted for 71.7% of injury mechanisms and stab wounds accounted for the remaining 28.3%. Median injury severity score was 9 (interquartile range: 5-13). Two thousand one hundred and twenty-one (70.6%) patients sustained kidney injury, 1210 (40.3%) liver injury, and 159 (5.3%) splenic injury. NOM was pursued in 615 (20.5%) patients. Factors significantly associated with immediate operative intervention included GSW, hypotension, and associated hollow viscus injury. Failed NOM was identified in 175 patients (28.5%). Factors significantly associated with failed NOM included GSW, high-grade SOI, and associated hollow viscus injury. Overall mortality was 26 (0.9%). CONCLUSIONS: NOM can be safe in a carefully selected group of pediatric patients with penetrating SOI. Future prospective studies are warranted to validate its feasibility.

Efficacy of endoscopic ultrasound-guided fine-needle aspiration and core needle biopsy in the diagnosis of upper gastrointestinal submucosal lesions.

INTRODUCTION: Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) has been increasingly utilized to evaluate submucosal lesions of the upper gastrointestinal (UGI) tract. Our study aims to determine the efficacy of UGI EUS-FNA/core needle biopsy (CNB), including the frequency and cytomorphologic features of encountered submucosal lesions, and to investigate contributing factors including the role of rapid on-site evaluation (ROSE). METHODS: We analyzed all UGI submucosal lesions diagnosed at our institution by EUS-FNA/CNB from September 2008 through August 2015. RESULTS: During this 8-year study period, 94 patients underwent 110 UGI EUS-FNA/CNB, including 89 (81%) gastric, 11 (10%) duodenal, and 10 (9%) esophageal lesions. Twenty-seven (25%) were gastrointestinal stromal tumors (GISTs), followed by 13 (12%) leiomyomas, 5 (5%) schwannomas, 4 (4%) gastric adenocarcinomas, 3 (3%) neuroendocrine tumors (NETs), and 3 (3%) pancreatic heterotopias. All GISTs, leiomyomas, and NETs were ultimately diagnosed by EUS biopsies, as well as 75% of adenocarcinomas, 60% of schwannomas, and 33% of pancreatic heterotopias. The specificity of EUS-FNA/CNB for these 6 most commonly encountered lesions was 100%, with sensitivity of 82%. Sensitivity was 100% for esophageal and duodenal biopsies, and 80% and 75% for gastric and gastroesophageal procedures, respectively. Factors that contributed to poor yield included the lack of ROSE, small lesional size, lesion location and histology, and needle type. Neither number of needle passes nor operator experience appeared to influence specimen adequacy. CONCLUSION: EUS-FNA/CNB is an effective modality for diagnosing UGI submucosal lesions. Awareness of potential errors due to sampling of the bowel wall, lesional cystic degeneration, as well as pancreatic heterotopia and Brunner gland hamartoma is essential in order to avoid false diagnoses.

Recurrent papillary thyroid carcinoma with pleural metastasis diagnosed by effusion cytology: a report of cases with clinicopathologic correlation.

Papillary thyroid carcinoma (PTC) is typically an indolent disease characterized by slow growth and a favorable prognosis. In rare instances, this disease may metastasize to the pleura and manifest as a malignant pleural effusion. We report 3 female patients of Japanese/Okinawan ancestry with a history of PTC who presented with hydrothorax. Cytologic examination in conjunction with immunohistochemical staining enabled a definitive diagnosis of metastatic PTC. Molecular analysis of the mitogen activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways demonstrated the presence of the v-raf murine sarcoma viral oncogene homolog B (BRAF)(V600E) mutation in 2 of our 3 patients, with the absence of any other clinically significant mutations in all cases. Further investigation is necessary to elucidate the molecular and environmental mechanisms involved in this aggressive manifestation of PTC.

Symbiont polyphyly, co-evolution, and necessity in pentatomid stinkbugs from Costa Rica.

Interdomain symbioses with bacteria allow insects to take advantage of underutilized niches and provide the foundation for their evolutionary success in neotropical ecosystems. The gut microbiota of 13 micro-allopatric tropical pentatomid species, from a Costa Rican lowland rainforest, was characterized and compared with insect and host plant phylogenies. Like other families within the Pentatomomorpha, these insects (within seven genera-Antiteuchus, Arvelius, Edessa, Euschistus, Loxa, Mormidea, and Sibaria) house near-monocultures of gamma-proteobacteria in midgut crypts, comprising three distinct lineages within the family Enterobacteriaceae. Identity of the dominant bacteria (78-100% of the recovered 16S rRNA genes) was partially congruent with insect phylogeny, at the level of subfamily and tribe, with bacteria closely related to Erwinia observed in six species of the subfamily Pentatominae, and bacteria in a novel clade of Enterobacteriaceae for seven species within the subfamilies Edessinae and Discocephalinae. Symbiont replacement (i.e., bacterial "contamination" from the environment) may occur during maternal transmission by smearing of bacteria onto the egg surfaces during oviposition. This transmission strategy was experimentally confirmed for Sibaria englemani, and suspected for four species from two subfamilies, based on observation of egg probing by nymphs. Symbiont-deprived S. englemani, acquired via egg surface sterilization, exhibited significantly extended second instars (9.1 days compared with 7.9 days for symbiotic nymphs; p = 0.0001, Wilcoxon's rank with Bonferroni correction), slower linearized growth rates (p = 0.005, Welch 2-sample t-test), and qualitative differences in ceca morphology, including increased translucency of crypts, elongation of extracellular cavities, and distribution of symbionts, compared to symbiotic nymphs. Combined, these results suggest a role of the symbiont in host development, the reliable transference of symbionts via egg surfaces, and a suggestion of co-evolution between symbiont and tropical pentatomid host insects.

Ontogenetic variation in epibiont community structure in the deep-sea yeti crab, Kiwa puravida: convergence among crustaceans.

Recent investigations have demonstrated that unusually 'hairy' yeti crabs within the family Kiwaidae associate with two predominant filamentous bacterial families, the Epsilon and Gammaproteobacteria. These analyses, however, were based on samples collected from a single body region, the setae of pereopods. To more thoroughly investigate the microbiome associated with Kiwa puravida, a yeti crab species from Costa Rica, we utilized barcoded 16S rRNA amplicon pyrosequencing, as well as microscopy and terminal restriction fragment length polymorphism analysis. Results indicate that, indeed, the bacterial community on the pereopods is far less diverse than on the rest of the body (Shannon indices ranged from 1.30-2.02 and 2.22-2.66, respectively). Similarly, the bacterial communities associated with juveniles and adults were more complex than previously recognized, with as many as 46 bacterial families represented. Ontogenetic differences in the microbial community, from egg to juvenile to adult, included a dramatic under-representation of the Helicobacteraceae and higher abundances of both Thiotrichaceae and Methylococcaceae for the eggs, which paralleled patterns observed in another bacteria-crustacean symbiosis. The degree to which abiotic and biotic feedbacks influence the bacterial community on the crabs is still not known, but predictions suggest that both the local environment and host-derived factors influence the establishment and maintenance of microbes associated with the surfaces of aquatic animals.