Evaluating no fixation, endoscopic suture fixation, and an over-the-scope clip for anchoring fully covered self-expanding metal stents in benign upper gastrointestinal conditions: a comparative multicenter international study (with video).

BACKGROUND AND AIMS: Fully covered self-expandable metal stents (FCSEMSs) are widely used in benign upper gastrointestinal (GI) conditions, but stent migration remains a limitation. An over-the-scope clip (OTSC) device (Ovesco Endoscopy) for stent anchoring has been recently developed. The aim of this study was to evaluate the effect of OTSC fixation on SEMS migration rate. METHODS: A retrospective review of consecutive patients who underwent FCSEMS placement for benign upper GI conditions between 1/2011 and 10/2022 at 16 centers. The primary outcome was rate of stent migration. The secondary outcomes were clinical success and adverse events. RESULTS: A total of 311 (no fixation 122, OTSC 94, endoscopic suturing 95) patients underwent 316 stenting procedures. Compared to the no fixation (NF) group (n=49, 39%), the rate of stent migration was significantly lower in the OTSC (SF) (n=16, 17%, p=0.001) and endoscopic suturing (ES) group (n=23, 24%, p=0.01). The rate of stent migration was not different between the SF and ES groups (p=0.2). On multivariate analysis, SF (OR 0.34, CI 0.17-0.70, p<0.01) and ES (OR 0.46, CI 0.23-0.91, p=0.02) were independently associated with decreased risk of stent migration. Compared to the NF group (n=64, 52%), there was a higher rate of clinical success in the SF (n=64, 68%; p=0.03) and ES group (n=66, 69%; p = 0.02). There was no significant difference in the rate of adverse events between the three groups. CONCLUSION: Stent fixation using OTSC is safe and effective at preventing stent migration and may also result in improved clinical response.

US Nationwide Insight Into All-cause 30-day Readmissions following Inpatient Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data. METHODS: Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission. RESULTS: A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52, P <0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10, P =0.008). CONCLUSION: All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.

Particle-associated and free-living bacterial communities in an oligotrophic sea are affected by different environmental factors.

In the oceans and seas, environmental conditions change over multiple temporal and spatial scales. Here, we ask what factors affect the bacterial community structure across time, depth and size fraction during six seasonal cruises (2 years) in the ultra-oligotrophic Eastern Mediterranean Sea. The bacterial community varied most between size fractions (free-living (FL) vs. particle-associated), followed by depth and finally season. The FL community was taxonomically richer and more stable than the particle-associated (PA) one, which was characterized by recurrent 'blooms' of heterotrophic bacteria such as Alteromonas and Ralstonia. The heterotrophic FL and PA communities were also correlated with different environmental parameters: the FL population correlated with depth and phytoplankton, whereas PA bacteria were correlated primarily with the time of sampling. A significant part of the variability in community structure could, however, not be explained by the measured parameters. The metabolic potential of the PA community, predicted from 16S rRNA amplicon data using PICRUSt, was enriched in pathways associated with the degradation and utilization of biological macromolecules, as well as plastics, other petroleum products and herbicides. The FL community was enriched in predicted pathways for the metabolism of inositol phosphate, a potential phosphorus source, and of polycyclic aromatic hydrocarbons.

Temporal Stability of the Healthy Human Skin Microbiome Following Dead Sea Climatotherapy.

Dead Sea climatotherapy (DSC) is a therapeutic modality for a variety of chronic skin conditions, yet there has been scarce research on the relationship between the cutaneous microbiota and disease states in response to DSC. We characterized the skin bacterial and fungal microbiome of healthy volunteers who underwent DSC. Bacterial community diversity remained similar before and after treatment, while fungal diversity was significantly reduced as a result of the treatment. Individuals showed greater inter-individual than temporal bacterial community variance, yet the opposite was true for fungal community composition. We further identified Malassezia as the genus driving temporal mycobiome variations. The results indicate that the microbiome remains stable throughout DSC, while the mycobiome undergoes dramatic community changes. The results of this study will serve as an important baseline for future investigations of microbiome and mycobiome temporal phenomena in diseased states.

Biofouling of reverse osmosis membranes: effects of cleaning on biofilm microbial communities, membrane performance, and adherence of extracellular polymeric substances.

Laboratory-scale reverse osmosis (RO) flat-sheet systems were used with two parallel flow cells, one treated with cleaning agents and a control (ie undisturbed). The cleaning efforts increased the affinity of extracellular polymeric substances (EPS) to the RO membrane and altered the biofilm surface structure. Analysis of the membrane biofilm community composition revealed the dominance of Proteobacteria. However, within the phylum Proteobacteria, γ-Proteobacteria dominated the cleaned membrane biofilm, while ß-Proteobacteria dominated the control biofilm. The composition of the fungal phyla was also altered by cleaning, with enhancement of Ascomycota and suppression of Basidiomycota. The results suggest that repeated cleaning cycles select for microbial groups that strongly attach to the RO membrane surface by producing rigid and adhesive EPS that hampers membrane performance.

The role of stress in colicin regulation.

Bacteriocins produced by Enterobacteriaceae are high molecular weight toxic proteins that kill target cells through a variety of mechanisms, including pore formation and nucleic acid degradation. What is remarkable about these toxins is that their expression results in death to the producing cells and therefore bacteriocin induction have to be tightly regulated, often confined to times of stress. Information on the regulation of bacteriocins produced by enteric bacteria is sketchy as their expression has only been elucidated in a handful of bacteria. Here, we review the known regulatory mechanisms of enteric bacteriocins and explore the expression of 12 of them in response to various triggers: DNA-damaging agents, stringent response, catabolite repression, oxidative stress, growth phase, osmolarity, cold shock, nutrient deprivation, anaerobiosis and pH stress. Our results indicate that the expression of bacteriocins is mostly confined to mutagenic triggers, while all other triggers tested are limited inducers.

The effect of temperature on fouling in anaerobic membrane bioreactor: SMP- and EPS-membrane interactions.

Biofouling is the main challenge in the operation of anaerobic membrane bioreactors (AnMBRs). Biofouling strongly depends on temperature; therefore, we hypothesize that the interactions and viscoelastic properties of soluble microbial products (SMP) and extracellular polymeric substances (EPS) vary with temperature, consequently influencing membrane permeability. This study compares the performance of an AnMBR operated at a similar permeate flux at two temperatures. The transmembrane pressure (TMP) rose rapidly after 5 ± 2 days at 25 °C but only after 18 ± 2 days at 35 °C, although the reactor's biological performance was similar at both temperatures, in terms of the efficiency of dissolved organic carbon removal and biogas composition, which were obtained by changing the hydraulic retention time. Using confocal laser scanning microscopy (CLSM), a higher biofilm amount was detected at 25 °C than at 35 °C, while quartz crystal microbalance with dissipation (QCM-D) showed a more adhesive, but less viscous and elastic EPS layer. In situ optical coherence tomography (OCT) of an ultra-filtration membrane, fed with the mixed liquor suspended solids (MLSS) at the two temperatures, revealed that while a higher rate of TMP increase was obtained at 25 °C, the attachment of biomass from MLSS was markedly less. Increased EPS adhesion to the membrane can accelerate TMP increase during the operation of both the AnMBR and the OCT filtration cell. EPS's reduced viscoelasticity at 25 °C suggests reduced floc integrity and possible increased EPS penetration into the membrane pores. Analysis of the structures of the microbial communities constituting the AnMBR flocs and membrane biofilms reveals temperature's effects on microbial richness, diversity, and abundance, which likely influence the observed EPS properties and consequent AnMBR fouling.

Two endoscopic suturing techniques for the prevention of percutaneous gastrojejunostomy tube retrograde migration.

Video 1Two suturing techniques for the fixation of percutaneous gastrojejunostomy tubes.

Spontaneous Infection of a Nonmalignant Intraductal Papillary Mucinous Neoplasm.

Intraductal papillary mucinous neoplasm (IPMN) is a pancreatic tumor that originates from the epithelium of the pancreatic duct. Although IPMN cysts can be complicated by infection, this has been reported to involve cysts that have ruptured, fistulized into surrounding organs, undergone malignant transformation, or were recently sampled. We present a 76-year-old man with a history of an IPMN who developed spontaneous cyst infection which was managed with fine-needle aspiration and antibiotics. To the best of our knowledge, this is the first reported case of spontaneous infection of a nonmalignant IPMN. Cyst infection should be considered as a very rare cause of unexplained fevers in patients with history of IPMN.

Acid-suppressive therapy among infants and risk of anemia at 12 months of age.

Objectives: Numerous studies have shown that links exist between exposure to acid suppression among adults and nutritional deficiencies, especially vitamin B12 and iron. While the use of acid suppression among children and infants is common, nutritional deficiency remains a concern but does not have numerous studies to support it. We conducted a cohort study to examine this concern; the hypothesis we proposed is that acid-suppressive therapy (AST) during infancy is linked to anemia in the first year of life. Methods: This retrospective cohort study included infants born between 2017 and 2018 who visited Legacy Community Health. The inclusion criteria were exposure to acid suppression for a minimum of 1 month and a hemoglobin reading at 12-15 months. Infants who had hemoglobinopathies, failure to thrive, or malabsorption syndromes were excluded. Mean hemoglobin was calculated, and student's t-test was applied to find statistical differences between the two groups. Change in weight before and after treatment was recorded. Occurrence of respiratory and gastroenterological adverse events was recorded in the exposed group. Results: Overall, 135 exposed infants were identified 135 controls were selected. The majority of the sample included Hispanic girls. Ranitidine was the most commonly prescribed medicine. The duration of treatment was 3 months. Weight improved significantly at termination of the treatment. There was no significant difference between the hemoglobin level of cases and controls, and both were not considered anemic. Conclusion: AST was not linked to anemia, despite the slightly lower hemoglobin in some cases. There were few weaknesses in our study; therefore, further studies can examine this link by focusing further on medication type and close follow-up. We found that although proton pump inhibitors are considered the first line of treatment, histamine-2 receptor antagonists were more frequently prescribed. Strategies to familiarize general pediatricians with the NSAPGHAN guidelines might be needed.

Antiscalants Used in Seawater Desalination: Biodegradability and Effects on Microbial Diversity.

Antiscalants are organic polymers widely used for scale inhibition in seawater desalination. While they are susceptible to biodegradation, they provide nutrients for bacterial cell growth and energy for the microbes that assimilate and degrade them. This paper shows the biodegradability of three commercial antiscalants (polyacrylate-CA, polyphosphonate-PP, and carboxylated dendrimers-DN) applied in seawater reverse osmosis desalination (SWRO) as well as analyzing the antiscalant's effects on microbial diversity using microbial cultures grown in seawater, under semi-continuous batch conditions. Nutritional uptake and contribution of the antiscalants to microbial growth were investigated by measuring DOC, TDN, NO3-, NO2-, PO4-, NH4+, and TP of the filtered samples of the incubated batch, twice a month, for twelve months. The microbial community was estimated by 16S rRNA sequencing. The main changes in the microbial communities were determined by the incubation period. However, bacterial orders of the antiscalant treatments differed significantly from the control treatment, namely Planctomycetales, Clostridiales, Sphingobacteriales, Rhodobacterales, and Flavobacteriales, and other unclassified bacterial orders, which were found in various relative abundances dependent on incubation times. The results showed the PP antiscalant to be the least biodegradable and to have the least effect on the bacterial community composition compared to the control. This result emphasizes the need to reassess the suitability criteria of antiscalants, and to further monitor their long-term environmental effects.

Sparus aurata and Lates calcarifer skin microbiota under healthy and diseased conditions in UV and non-UV treated water.

BACKGROUND: The welfare of farmed fish is influenced by numerous environmental and management factors. Fish skin is an important site for immunity and a major route by which infections are acquired. The objective of this study was to characterize bacterial composition variability on skin of healthy, diseased, and recovered Gilthead Seabream (Sparus aurata) and Barramundi (Lates calcarifer). S. aurata, which are highly sensitive to gram-negative bacteria, were challenged with Vibrio harveyi. In addition, and to provide a wider range of infections, both fish species (S. aurata and L. calcarifer) were infected with gram-positive Streptococcus iniae, to compare the response of the highly sensitive L. calcarifer to that of the more resistant S. aurata. All experiments also compared microbial communities found on skin of fish reared in UV (a general practice used in aquaculture) and non-UV treated water tanks. RESULTS: Skin swab samples were taken from different areas of the fish (lateral lines, abdomen and gills) prior to controlled infection, and 24, 48 and 72 h, 5 days, one week and one-month post-infection. Fish skin microbial communities were determined using Illumina iSeq100 16S rDNA for bacterial sequencing. The results showed that naturally present bacterial composition is similar on all sampled fish skin sites prior to infection, but the controlled infections (T1 24 h post infection) altered the bacterial communities found on fish skin. Moreover, when the naturally occurring skin microbiota did not quickly recover, fish mortality was common following T1 (24 h post infection). We further confirmed the differences in bacterial communities found on skin and in the water of fish reared in non-UV and UV treated water under healthy and diseased conditions. CONCLUSIONS: Our experimental findings shed light on the fish skin microbiota in relation to fish survival (in diseased and healthy conditions). The results can be harnessed to provide management tools for commercial fish farmers; predicting and preventing fish diseases can increase fish health, welfare, and enhance commercial fish yields.

Freshwater microbial metagenomes sampled across different water body characteristics, space and time in Israel.

Freshwater bodies are critical components of terrestrial ecosystems. The microbial communities of freshwater ecosystems are intimately linked water quality. These microbes interact with, utilize and recycle inorganic elements and organic matter. Here, we present three metagenomic sequence datasets (total of 182.9 Gbp) from different freshwater environments in Israel. The first dataset is from diverse freshwater bodies intended for different usages - a nature reserve, irrigation and aquaculture facilities, a tertiary wastewater treatment plant and a desert rainfall reservoir. The second represents a two-year time-series, collected during 2013-2014 at roughly monthly intervals, from a water reservoir connected to an aquaculture facility. The third is from several time-points during the winter and spring of 2015 in Lake Kinneret, including a bloom of the cyanobacterium Microcystis sp. These datasets are accompanied by physical, chemical, and biological measurements at each sampling point. We expect that these metagenomes will facilitate a wide range of comparative studies that seek to illuminate new aspects of freshwater microbial ecosystems and inform future water quality management approaches.

Temporal and Spatial Changes in Phyllosphere Microbiome of Acacia Trees Growing in Arid Environments.

Background: The evolutionary relationships between plants and their microbiomes are of high importance to the survival of plants in general and even more in extreme conditions. Changes in the plant's microbiome can affect plant development, growth, fitness, and health. Along the arid Arava, southern Israel, acacia trees (Acacia raddiana and Acacia tortilis) are considered keystone species. In this study, we investigated the ecological effects of plant species, microclimate, phenology, and seasonality on the epiphytic and endophytic microbiome of acacia trees. One hundred thirty-nine leaf samples were collected throughout the sampling year and were assessed using 16S rDNA gene amplified with five different primers (targeting different gene regions) and sequenced (150 bp paired-end) on an Illumina MiSeq sequencing platform. Results: Epiphytic bacterial diversity indices (Shannon-Wiener, Chao1, Simpson, and observed number of operational taxonomic units) were found to be nearly double compared to endophyte counterparts. Epiphyte and endophyte communities were significantly different from each other in terms of the composition of the microbial associations. Interestingly, the epiphytic bacterial diversity was similar in the two acacia species, but the canopy sides and sample months exhibited different diversity, whereas the endophytic bacterial communities were different in the two acacia species but similar throughout the year. Abiotic factors, such as air temperature and precipitation, were shown to significantly affect both epiphyte and endophytes communities. Bacterial community compositions showed that Firmicutes dominate A. raddiana, and Proteobacteria dominate A. tortilis; these bacterial communities consisted of only a small number of bacterial families, mainly Bacillaceae and Comamonadaceae in the endophyte for A. raddiana and A. tortilis, respectively, and Geodematophilaceae and Micrococcaceae for epiphyte bacterial communities, respectively. Interestingly, ~60% of the obtained bacterial classifications were unclassified below family level (i.e., "new"). Conclusions: These results shed light on the unique desert phyllosphere microbiome highlighting the importance of multiple genotypic and abiotic factors in shaping the epiphytic and endophytic microbial communities. This study also shows that only a few bacterial families dominate both epiphyte and endophyte communities, highlighting the importance of climate change (precipitation, air temperature, and humidity) in affecting arid land ecosystems where acacia trees are considered keystone species.