Background/Aims: To describe the role of ustekinumab in inducing remission and endoscopic healing in anti-tumor necrosis factor α nonresponsive pediatric ulcerative colitis patients at a tertiary care inflammatory bowel disease center. Methods: A retrospective chart review was performed on patients with ulcerative colitis receiving ustekinumab. Primary outcome was steroidfree clinical remission at follow-up. Secondary outcomes were biochemical remission and endoscopic healing. Results: Ten children were analyzed; 7 (70%) had ulcerative colitis, and 3 (30%) had inflammatory bowel disease unspecified with colitis. Median follow-up period was 56 weeks. Nine patients (90%) achieved steroid-free clinical remission and biochemical remission. Seven patients had follow-up colonoscopies, out of which 6 (86%) achieved endoscopic remission, while 1 (14%) underwent colectomy. Out of the 3 patients without a follow-up colonoscopy, fecal calprotectin levels downtrended to < 150 mg/kg in 2 patients and < 400 mg/kg in 1 patient from baseline level of > 2,000 mg/kg. Conclusions Ustekinumab appears efficacious in achieving not only clinical and biochemical remission but also has promising role in inducing endoscopic healing end point in patients who fail other biologics.

Background: and Purpose Venous thromboembolism (VTE) is a life-threatening complication of stroke. We evaluated nationwide rates and risk factors for hospital readmissions with VTE after an intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS) hospitalization. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included patients with a principal discharge diagnosis of ICH or AIS from 2016 to 2019. Patients who had VTE diagnosis or history of VTE during the index admission were excluded. We performed Cox regression models to determine factors associated with VTE readmission, compared rates between AIS and ICH and developed post-stroke VTE risk score. We estimated VTE readmission rates per day over a 90-day time window post-discharge using linear splines. Results: Of the total 1,459,865 patients with stroke, readmission with VTE as the principal diagnosis within 90 days occurred in 0.26% (3,407/1,330,584) AIS and 0.65% (843/129,281) ICH patients. The rate of VTE readmission decreased within first 4–6 weeks (P<0.001). In AIS, cancer, obesity, higher National Institutes of Health Stroke Scale (NIHSS) score, longer hospital stay, home or rehabilitation disposition, and absence of atrial fibrillation were associated with VTE readmission. In ICH, longer hospital stay and rehabilitation disposition were associated with VTE readmission. The VTE rate was higher in ICH compared to AIS (adjusted hazard ratio 2.86, 95% confidence interval 1.93–4.25, P<0.001). Conclusions After stroke, VTE readmission risk is highest within the first 4–6 weeks and nearly three-fold higher after ICH vs. AIS. VTE risk is linked to decreased mobility and hypercoagulability. Studies are needed to test short-term VTE prophylaxis beyond hospitalization in high-risk patients.

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: “(laparoscopic OR endoscopic) AND (anterior AND lumbar).” Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio’s “metafor” package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6–43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9–90.4). Complications occurred in 19.2% (95% CI, 13.4–27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6–11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

Purpose: Cow’s milk protein allergy (CMPA) is a common condition in infants, but little is known about healthcare providers’ clinical experience treating infants with CMPA. To address this gap, we analyzed prospectively collected data from healthcare providers (HCPs) who treated infants under six months old with suspected CMPA using hypoallergenic formulas.The study focused on a commercial extensively hydrolyzed formula containing Lactobacillus rhamnosus GG (ATCC53103) (eHF-LGG) or a commercial amino acid formula (AAF). Methods: In this secondary analysis of prospectively collected survey data, 52 HCPs treated 329 infants under six months old with suspected CMPA using hypoallergenic formulas. A series of two de-identified surveys per patient were collected by HCPs to assess short-term symptom relief in the patients and HCP’s satisfaction with the management strategies. The initial survey was completed at the initiation of treatment of CMPA, and the second survey was completed at a follow-up visit. Results: The majority of HCPs (87%) in the study were general pediatricians, and most saw 2 to 10 CMPA patients weekly. Results showed that clinicians reported satisfaction with treatment in 95% of patients in the EHF cohort and 97% of patients in the AAF cohort and achieved expected clinical results in 93% and 97% of patients using eHF and AAF, respectively.Furthermore, few patients were switched from the hypoallergenic formula once initiated. Conclusion The study provides new insights into HCP perspectives on treating infants with CMPA and supports using hypoallergenic formulas to manage this condition. However, additional prospective controlled studies are needed to confirm these initial findings.

Purpose: Histopathologic analysis of femoral head specimens following total hip arthroplasty (THA) is a routine practice that represents a significant use of health care resources. However, it occasionally results in discovery of undiagnosed hematopoietic malignancy and other discrepant diagnoses such as avascular necrosis. The purpose of this study was to determine the rate of discordant and discrepant diagnoses discovered from routine histopathological evaluation of femoral heads following THA and perform a cost analysis of this practice. Materials and Methods: A review of patients undergoing primary THA between 2004-2017 was conducted. A comparison of the surgeon’s preoperative and postoperative diagnosis, and the histopathologic diagnosis was performed. In cases where the clinical and histopathology differed, a review determined whether this resulted in a change in clinical management. Medicare reimbursement and previously published cost data corrected for inflation were utilized for cost calculations. Results: A review of 2,134 procedures was performed. The pathologic diagnosis matched the postoperative diagnosis in 96.0% of cases. Eighty-three cases (4.0%) had a discrepant diagnosis where treatment was not substantially altered. There was one case of discordant diagnosis where lymphoma was diagnosed and subsequently treated. The cost per discrepant diagnosis was $141,880 and per discordant diagnosis was $1,669 when using 100% Medicare reimbursement and Current Procedural Terminology (CPT) code combination 88304+88311. Conclusion Histopathologic analysis of femoral head specimens in THAs showed an association with high costs given the rarity of discordant diagnoses. Routine use of the practice should be at the discretion of individual hospitals with consideration for cost and utility thresholds.

Purpose: Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients. Methods: A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016.Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified.Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement. Results: The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre-(–1.11) to post- (–0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEGrelated death documented. Conclusion Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia.Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

Background: Preoperative radiographic templating for total knee arthroplasty (TKA) has been shown to be inaccurate. Patient demographic data, such as gender, height, weight, age, and race, may be more predictive of implanted component size in TKA. Materials and methods: A multivariate linear regression model was designed to predict implanted femoral and tibial component size using demographic data along a consecutive series of 201 patients undergoing index TKA.Traditional, two-dimensional, radiographic templating was compared to demographic-based regression predictions on a prospective 181 consecutive patients undergoing index TKA in their ability to accurately predict intraoperative implanted sizes. Surgeons were blinded of any predictions. Results: Patient gender, height, weight, age, and ethnicity/race were predictive of implanted TKA component size.The regression model more accurately predicted implanted component size compared to radiographically templated sizes for both the femoral (P = 0.04) and tibial (P < 0.01) components. The regression model exactly predicted femoral and tibial component sizes in 43.7 and 43.7% of cases, was within one size 90.1 and 95.6% of the time, and was within two sizes in every case. Radiographic templating exactly predicted 35.4 and 36.5% of cases, was within one size 86.2 and 85.1% of the time, and varied up to four sizes for both the femoral and tibial components. The regression model averaged within 0.66 and 0.61 sizes, versus 0.81 and 0.81 sizes for radiographic templating for femoral and tibial components. Conclusions A demographic-based regression model was created based on patient-specific demographic data to predict femoral and tibial TKA component sizes. In a prospective patient series, the regression model more accurately and precisely predicted implanted component sizes compared to radiographic templating.Level of evidence: Prospective cohort, level II.

Background: Preoperative radiographic templating for total knee arthroplasty (TKA) has been shown to be inaccurate. Patient demographic data, such as gender, height, weight, age, and race, may be more predictive of implanted component size in TKA. Materials and methods: A multivariate linear regression model was designed to predict implanted femoral and tibial component size using demographic data along a consecutive series of 201 patients undergoing index TKA.Traditional, two-dimensional, radiographic templating was compared to demographic-based regression predictions on a prospective 181 consecutive patients undergoing index TKA in their ability to accurately predict intraoperative implanted sizes. Surgeons were blinded of any predictions. Results: Patient gender, height, weight, age, and ethnicity/race were predictive of implanted TKA component size.The regression model more accurately predicted implanted component size compared to radiographically templated sizes for both the femoral (P = 0.04) and tibial (P < 0.01) components. The regression model exactly predicted femoral and tibial component sizes in 43.7 and 43.7% of cases, was within one size 90.1 and 95.6% of the time, and was within two sizes in every case. Radiographic templating exactly predicted 35.4 and 36.5% of cases, was within one size 86.2 and 85.1% of the time, and varied up to four sizes for both the femoral and tibial components. The regression model averaged within 0.66 and 0.61 sizes, versus 0.81 and 0.81 sizes for radiographic templating for femoral and tibial components. Conclusions A demographic-based regression model was created based on patient-specific demographic data to predict femoral and tibial TKA component sizes. In a prospective patient series, the regression model more accurately and precisely predicted implanted component sizes compared to radiographic templating.Level of evidence: Prospective cohort, level II.

Background: Antibiotic-loaded bone cement (ALBC) is commonly used in total knee arthroplasty (TKA), especially among high-risk patients. While previous studies have reported on the efficacy of ALBC in reducing the rate of periprosthetic joint infection (PJI), its impact on antibiotic resistance has not been determined. The purpose of this study was to investigate antibiotic resistance among organisms causing PJIs after TKA in which ALBC was utilized. Methods: A retrospective review from December 1998 through December 2017 identified 36 PJIs that met inclusion criteria. Patients with culture-negative infection and unknown cement type were excluded. Patient characteristics, infecting organism, and antibiotic susceptibilities were recorded. ABLC included an aminoglycoside in all cases. Results: There was no difference in the type of PJI between the 2 groups. Staphylococcus species was the most commonly isolated, with 9 of 16 cases (56.3%) using non-ALBC and 14 of 20 (65.0%) cases using ALBC. Of those infected with Staphylococcus, there was no significant difference in antibiotic susceptibilities between groups. Overall, there were only 3 cases where the infecting organism was aminoglycoside resistant (standard cement, 1; ALBC, 2). Conclusions These results suggest that the use of ALBC does not increase the risk of antibiotic resistance or affect the pattern of infection, even as the use of ALBC continues to increase, particularly among high-risk patients.

We report the case of a seven-year-old boy with an ingested foreign body, which was retained within the appendix for a known duration of ten months, ultimately requiring appendectomy. The ingested foreign body was incidentally discovered by abdominal x-ray at an emergency room visit for constipation. Despite four bowel cleanouts, subsequent x-rays showed persistence of the foreign body in the right lower quadrant. While the patient did not have signs or symptoms of acute appendicitis, laparoscopic appendectomy was performed due to the risk of this foreign body causing appendicitis in the future. A small metallic object was found within the appendix upon removal. This case highlights the unique challenge presented by foreign body ingestions in non-verbal or developmentally challenged children and the importance of further diagnostic workup when concerns arise for potential retained foreign bodies.
Appendectomy ; Appendicitis ; Appendix ; Autism Spectrum Disorder ; Child ; Constipation ; Emergency Service, Hospital ; Endoscopy ; Foreign Bodies ; Gastroenterology ; Humans ; Male ; Pediatrics