Docosahexaenoic Acid in Mature Breast Milk of Low-Income Mothers

Docosahexaenoic acid (DHA) is among the main components of synaptosomal membranes and myelin sheaths. Since DHA is essential for child neurodevelopment, breast milk DHA levels should be improved by optimizing maternal nutrition. We determined DHA percentage levels in breast milk of low-income mothers receiving care at the public healthcare sector. We performed a descriptive, cross-sectional study in breast milk samples from 39 exclusively breastfeeding adult mothers with normal fetal and neonatal history. Samples were collected 90 ± 7 days after delivery. Breast milk fatty acid composition was determined by gas chromatography. The cut-off value of DHA was 0.3% of total fatty acids in milk according to recommendations. Median DHA in milk was 0.14% (0.12–0.21). Breast milk DHA levels were lower than the minimum recommended in 92% of samples. The analysis of breast milk samples from low-income exclusively breastfeeding mothers showed that they did not reach the minimum recommended DHA percentage. Address correspondence and reprint requests to Silvana Visentin, IDIP – Instituto de Desarrollo e Investigaciones Pediátricas "Prof. Dr. Fernando E. Viteri", Hospital de Niños "Sor María Ludovica" de La Plata,Calle 63 N° 1069, 1900 La Plata, Argentina (e-mail: silvisentin@hotmail.com). Received 6 June, 2018 Accepted 29 December, 2018 This study received funding from IDIP. Author Contribution Silvana Visentin: conception of study design, acquisition and analysis of samples, drafting and revision of the final version of the work. Agustina Malpeli: concpetion of study design and carrying out of nutritional questionnaires. Victoria Fasano: conception of study design and biostatistical analysis of data. Mariana Falivene: clinical assessment of mothers, sample collection and revision of the final version of the work. Betiana E. Malizia: clinical assessment of mothers, sample collection and revision of the final version of the work. Horacio F. González: conception of study design, drafting and revision of the final version of the work. All authors approved the final version of the work to be published. Conflicts of interest and Source of Funding: The authors report no conflicts of interests. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Impact of Immunosuppression On Executive Functioning After Pediatric Liver Transplantation: An Observational Cohort Study

Objectives: Children after liver transplantation (LTx) show increased rates of impaired cognitive functioning. We aimed to assess the potential effects of immunosuppressive therapy on executive functioning measured by the Children's Colour Trail Test (CCTT) and the cognitive functioning module of the PedsQL (cogPedsQL) in liver transplanted children in order to explore potential targets for intervention to improve executive functioning. Methods: We performed a cross-sectional study in 155 children (78 female) aged 10.4 (2–18) years at 5.0 (0.1–17) years after LTx, with follow-up at 6 months in n = 114. Executive functioning was assessed by CCTT (ages 8–16) and by patients & parent-proxy cogPedsQL. (ages 5–18/2–18 respectively). Results were correlated with clinical parameters. Stability of results over time was compared between n = 23 patients who for clinical reasons switched from twice daily calcineurin inhibitor (CNI) to once-daily slow-release tacrolimus during the study period, and patients with unchanged CNI. Results: Worse executive functioning was associated with longer stay in the ICU and longer time elapsed since transplantation. No difference was found between users of cyclosporin and tacrolimus. Children on once-daily slow-release tacrolimus performed better than children on twice-daily tacrolimus. In children who switched from twice-daily CNI to once-daily tacrolimus, parent-proxy cogPedsQL improved significantly compared to stable results in the non-switch group. Conclusions: Besides a strong impact of disease burden around transplantation, executive functioning appears to deteriorate over time. While there is no clear-cut advantage of any CNI, once-daily tacrolimus appears to be advantageous compared to twice-daily tacrolimus. Address correspondence and reprint requests to Imeke Goldschmidt, Hannover Medical School, Paediatric Gastroenterology and Hepatology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany (e-mail: goldschmidt.imeke@mh-hannover.de). Received 12 June, 2018 Accepted 22 December, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Authorship contributions: Imeke Goldschmidt: participated in research design, organised and performed data acquisition, performed data analysis and wrote the first draft of the manuscript Rolf van Dick: contributed to research design, data analysis and interpretation, and participated in writing the manuscript Ulrich Baumann: initiated and participated in research design, and participated in data interpretation and in writing the manuscript Christoph Jacobi: participated in translation of the PedsQL cognitive functioning module, participated in data acquisition and made important contributions to the manuscript Norman Junge: supported patient acquisition and made important contributions to the manuscript Eva Doreen Pfister: supported patient acquisition and made important contributions to the manuscript Nico Richter: supported patient acquisition and made important contributions to the manuscript Conflicts of interests and sources of funding: This study was supported by an unrestricted grant by Astellas Pharma. Since an analysis of effect of immunosuppression on cognitive functioning is included in the study, this may be perceived as a conflict of interest. Astellas pharma did not participate in or influence data analysis or interpretation. The original PedsQL modul on cognitive functioning was provided by MAPI research trust for a structured translation. No funds were received for the translation. MAPI research trust did not participate in or influence data analysis or interpretation. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Clinical and Endoscopy Findings in Children with Accidental Exposure to Concentrated Detergent Pods

Background: Caustic ingestion with concentrated detergent pods (CDPs) is a common problem encountered in pediatric population. There is insufficient literature about endoscopic findings in CDP ingestion and hence no current consensus or guidelines regarding the need for endoscopic evaluation. Objectives: To review cases of children with exposure to CDPs from 2010–2016 at a tertiary care children's hospital and to identifying the possibility of a correlation between clinical presentation and the endoscopic findings. Methods: A retrospective review identified pediatric patients with accidental caustic exposure to CDPs. Data on demographics, type of exposure, clinical symptoms, physical exam, details of the hospital course, were collected. Esophago-Gastro-Duodenoscopy (EGD) findings and Direct Laryngoscopy-Bronchoscopy (DLB) findings were also collected. Descriptive statistics were computed for all demographic and clinical variables. The association between EGD findings and clinical presentation were tested using Fisher's exact test. Results: 23 (28%) cases of CDP Ingestion were identified out of 83 total cases of caustic ingestion between January 2010 and June 2016. Median age was 15 months. GI symptoms were present in 21 (91%) patients. Exam findings were present in 8/23 (35%) patients. EGD (done by gastroenterologists) evaluation was done in 21 (91%) patients and positive findings were seen in 5/21 (24%) The proportion of patients with positive exam findings was significantly higher in patients with positive EGD findings (80% vs 20%, respectively; p = 0.0307). DLB (done by otolaryngologists) evaluation was done in 6 (26%) patients and positive findings were seen in 4/6 (67%). Conclusion: Our results suggest that oropharyngeal exam findings increase the likelihood of endoscopy findings, hence we recommend endoscopic evaluation of patients who have exam findings secondary to exposure to CDPs. In other patients, it will be reasonable to evaluate the need for endoscopy on a case-by-case basis. Address correspondence and reprint requests to Avantika Singh, MD, 1200 Children's Ave, Oklahoma City, OK 73104 (e-mail: avantikasingh18@gmail.com). Received 2 January, 2018 Accepted 14 December, 2018 Authors have no financial disclosures or conflicts of interest to disclose. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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A Phase I/IIa Trial of Intravenous Immunoglobulin Following Portoenterostomy in Biliary Atresia

Objectives: Biliary atresia (BA) is a progressive neonatal fibroinflammatory cholangiopathy. We hypothesized that intravenous immunoglobulin (IVIg) would be safe, feasible, acceptable and efficacious for the treatment of BA. The primary objective of this study was to establish the feasibility, acceptability and safety profile of IVIg administration after hepatoportoenterostomy (HPE) in BA. The secondary objective was to determine the treatment efficacy of IVIg based on good bile drainage and survival with the native liver. Methods: A multi-center, prospective, open-labeled, phase I/IIA trial of IVIg was conducted, with 1 gm/kg/dose of IVIg infused at 3–5 days, 30 days and 60 days post-HPE, and subjects followed for 360 days post-HPE. Twenty-nine participants completed the study. Results: Administration of IVIg infusions was feasible and acceptable in 79%. None of the serious adverse events (SAEs) were directly related to IVIg infusions, however 90% of participants had an SAE. Compared to a historical placebo-arm group, there was no significant increase in the proportion of IVIg participants with a serum total bilirubin  0.05). Conclusions: Although IVIg infusions in infants with BA post-HPE were feasible, acceptable and safe, there was no trend to lower bilirubin levels or improved 360 day survival with the native liver. Clinical Trial: Safety Study of Intravenous Immunoglobulin Post-Portoenterostomy in Biliary Atresia; #NCT01854827. Address correspondence and reprint requests to Cara L. Mack, MD, Children's Hospital Colorado, 13123 E. 16th Ave., B290, Aurora, CO 80045 (e-mail: cara.mack@childrenscolorado.org). Received 5 August, 2018 Accepted 26 November, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Funding source: This work was supported by U01 grants from the National Institute of Diabetes, Digestive and Kidney Diseases (DK 62497 [to Dr. Bezerra], DK 62470 [to Dr. Karpen], DK 62481 [to Dr. Loomes], DK 62456 [to Ms. Spino], DK 62466 [to Dr. Venkat], DK 62453 [to Dr. Sokol], DK 84538 [to Dr. Wang], DK 62436 [to Dr. Alonso], and DK 642453 [to Dr. Ng]). In addition, the project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health,UL1 TR001878 [The Children's Hospital of Philadelphia], Clinical Translational Science AwardsUL1 TR002535 [University of Colorado Denver] and the Cincinnati Center for Translational Science and Training [Cincinnati Children's Hospital]. FFF Enterprises (Temecula, California) supplied and shipped the IVIg. Clinical Trial Registration: Safety Study of Intravenous Immunoglobulin (IVIG) Post-Portoenterostomy in Infants with Biliary Atresia (PRIME); #NCT01854827; http://bit.ly/2S1Gwy7 Contributors Statement: Drs. Cara Mack, and Ronald Sokol conceptualized and designed the study, coordinated and supervised data collection, assisted in data analyses, drafted the initial manuscript and edited the final version. Drs. Jorge Bezerra and Estella Alonso coordinated and supervised data collection, assisted in data analyses, drafted the initial manuscript and edited the final version. Cathie Spino and Jeffrey Moore carried performed all data analyses, provided biostatistical support and edited the final version. Drs. Vicky Ng, Saul Karpen, Venna Venkat, Kathleen Loomes, Kasper Wang and Catherine Goodhue coordinated and supervised data collection and edited the final version. Drs. Averell Sherker and John Magee assisted in the data analyses, provided important intellectual input and edited the final version. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Conflict of Interest and Source of Funding: The authors have no conflicts of interest or financial relationships with the sources of funding to disclose that are relevant to this article. No reprints requested. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Barriers in Neurogastroenterology and Motility Training Experience for Pediatric Gastroenterology Fellows

Background: Neurogastroenterology and motility (NGM) disorders are common and have a high health care burden. Although pediatric gastroenterology fellows are expected to obtain comprehensive training in the diagnosis and management of NGM disorders, there is ongoing concern for unmet training needs and lack of exposure in treating patients who suffer from NGM problems. Study Design: We conducted a cross-section survey of trainees listed as pediatric gastroenterology fellows in North American training programs in 2018 via direct E-mail and the pediatric gastroenterology listserv. Eighty-one pediatric gastroenterology fellows responded to the anonymous survey. Results: A total of 53.1% of the fellows reported interest in NGM, however, 75.1% of the fellows believed they had not been adequately trained in NGM during their fellowship. Eighty percent of fellows with two weeks or less of dedicated motility training reported that they received inadequate NGM training, compared to 46.2% fellows who received one or more months of dedicated motility training (p = 0.0148). The majority of fellows reported not being comfortable in performing gastrointestinal (GI) motility studies. The majority of fellows also reported not being comfortable in interpreting GI motility studies. Conclusion: While most pediatric gastroenterology fellows expressed interest in NGM, the lack of exposure and dedicated training in motility during fellowship were identified as barriers to pursuing motility-focused careers. Furthermore, most fellows reported limited comfort with performing and/or interpreting motility studies. Changes are needed to encourage fellows to develop their interest and expertise in NGM. Address correspondence and reprint requests to Kahleb Graham, MD, 3401 Civic Center Blvd, Philadelphia, PA 19104 (e-mail: grahamkd@email.chop.edu). Received 15 August, 2018 Accepted 27 December, 2018 © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Diagnostic and Therapeutic Approach in Paediatric Inflammatory Bowel Diseases – Results from a Clinical Practice Survey

Objectives: Despite existence of international guidelines for diagnosis and management of inflammatory bowel diseases (IBD) in children, there might be differences in the clinical approach. Methods: A survey on clinical practice in paediatric IBD was performed among members of the ESPGHAN Porto IBD working group and interest group, PIBD-NET, and IBD networks in Canada and German speaking countries (CIDsCANN, GPGE), using a web-based questionnaire. Responses to 63 questions from 106 paediatric IBD centres were collected. Results: Eighty-four percent of centres reported to fulfil the revised Porto criteria in the majority of patients. In luminal Crohn's disease (CD), exclusive enteral nutrition is used as a first line induction therapy and immunomodulators (IMM) are used since diagnosis in the majority of patients. Infliximab (IFX) is mostly considered as first-line biological. Sixty % of centres have experience with vedolizumab and/or ustekinumab and 40% use biosimilars. In the majority of ulcerative colitis (UC) patients 5-aminosalicylates are continued as concomitant therapy to IMM (usually AZA/6-MP). After ileocaecal resection (ICR) in CD patients without postoperative residual disease, AZA monotherapy is the preferred treatment. Conclusions: A majority of centres follows both the Porto diagnostic criteria as well as paediatric (ESPGHAN/ECCO) guidelines on medical and surgical IBD management. This reflects the value of international societal guidelines. However, potentially desirable answers might have been given instead of what is true daily practice, and the most highly motivated people might have answered, leading to some bias. Address correspondence and reprint requests to Jiri Bronsky, MD, PhD, Assoc. Prof. of Paediatrics, Gastroenterology and Nutrition Unit, Department of Paediatrics, University Hospital Motol, V Uvalu 84, 15006, Prague 5, Czech Republic (e-mail: jiri.bronsky@gmail.com). Received 30 August, 2018 Accepted 23 November, 2018 © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Insights into Pediatric Autoimmune Gastritis: Is There a Role for Helicobacter Pylori Infection?

Objectives: Autoimmune gastritis (AIG) is a chronic inflammatory condition of the gastric mucosa, mainly described in adults presenting with pernicious anemia. It results from antibody-mediated destruction of parietal cells, but the precise initiating event is unknown. The pathogenicity of Helicobacter pylori (H. pylori) has been suggested but not established. This study aimed to better characterize AIG in pediatric patients and to address the possible role of H. pylori infection. Methods: Descriptive single-center study, retrospectively describing 20 patients with a diagnosis of AIG based on positivity for anti-parietal cell autoantibodies (PCA), in addition to analytical and/or histological findings of oxyntic mucosa atrophy. Results: In the majority (18/20), AIG diagnosis was suggested during investigation of refractory iron-deficient anemia. One patient had dyspepsia and none of the others had gastrointestinal symptoms. Fifty five percent (11/20) were H. pylori positive, but there were no significant differences regarding mean Hemoglobin values at presentation (10.6 ± 2.5 g/dL vs. 9.5 ± 1.0 g/dL, p > 0.05), analytical indicators of gastric atrophy (gastrin, 564.4 ± 184 pg/mL vs. 721.2 ± 220.6 pg/mL, p > 0.05), nor in the presence or the grade of oxyntic mucosa atrophy. Conclusions: Our findings highlight that AIG may have an age-dependent presentation, thus we can consider a pediatric phenotype that in contrast to adults, is manifested by refractory iron-deficient anemia and associated with PCA positivity, but not intrinsic factor autoantibodies. A correlation between H. pylori and AIG was not evident in the current study and it is still unclear if H. pylori is a trigger for AIG. Address correspondence and reprint requests to Helena Moreira Silva, MD, Pediatric Gastroenterology Unit. Centro Materno Infantil do Norte – CMIN. Porto University Hospital Center. Porto, Portugal. Largo Prof. Abel Salazar 4099–001 Porto, Portugal (hel.m.silva@hotmail.com). Received 20 September, 2018 Accepted 8 January, 2019 Conflicts of interest and sources of funding: There are no funding sources. There are no financial disclosures and no conflict of Interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Biliary Tract Disease in Girls and Young Women with Rett Syndrome

Objective: We reviewed medical records and conducted a nationwide survey to characterize the clinical features and determine the prevalence of biliary tract disease in girls and women with Rett syndrome (RTT). Methods: Sixty-two individuals with RTT and biliary tract disease were identified from the membership of Rett Syndrome Organization (RS.O) and patient files of the principal investigator. Medical records of 46 individuals were reviewed for presenting features, diagnostic tests, and treatment outcomes of biliary tract disease. We designed a questionnaire that probed the frequency of risk factors and treatment outcomes of biliary tract disease in RTT. The questionnaire was completed by 271 parents whose daughters met the clinical criteria for RTT and/or had MECP2 mutations and participated in the Natural History of Rett Syndrome Study. Results: Presenting symptoms identified by record review included abdominal pain (94%), irritability (88%), weight loss (64%), and vomiting (52%). Biliary dyskinesia, cholecystitis, and cholelithiasis, were identified in 90%, 77%, and 70%, respectively, by cholescintigraphy, surgical pathology, and abdominal ultrasound. The prevalence of biliary tract disease was 4.4% (n = 12) in the RTT cohort. Risk factors included older age (p 

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Size and Prevalence of Pediatric Aerodigestive Programs in 2017

Objective: Pediatric aerodigestive programs appear to be rapidly proliferating and provide multi-disciplinary, coordinated care to complex, medically-fragile children. Pediatric subspecialists are considered essential to these programs. This study evaluated the state of these programs in 2017 by surveying their size, composition, prevalence, and the number of patients that they serve. Methods: The North American Society for Pediatric Gastroenterology Hepatology and Nutrition Aerodigestive Special Interest Group leadership distributed an 11-question survey to the Pediatric Gastroenterology International Listserv. The mean time of the programs' existence, number of half-day clinics, number of procedure days, number of patients evaluated and the lead primary specialty were evaluated. Results: Thirty-four programs responded. Twenty-five were based in academic centers. 31 programs were located across the United States. The average time of program existence was 5.3 years (SD 4.3 range 1–17 years). 64.7% were started in the past five years. Twelve programs were based in the division of gastroenterology. The average number of gastroenterologists serving aerodigestive programs was 2 (SD 1.1). The mean number of half-day clinic sessions and procedure days were 2.8 (SD 2.9) and 2.6 (SD 2) respectively. New and follow-up visits per year in each program averaged 184 (SD 168, range 10–750). Conclusion: Pediatric aerodigestive programs are prevalent, proliferating, and serve a large number of complex patients across North America and the world. This survey demonstrated that programs are predominantly based in academic settings. The number of patients cared for by aerodigestive centers varies widely depending on size and age of program Address correspondence and reprint requests to Joel A. Friedlander, Lindsey Gumer, Aerodigestive Program, Digestive Health Institute, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO (e-mails: Joel.Friedlander@childrenscolorado.org; lbgumer@gmail.com). Received 8 October, 2018 Accepted 1 January, 2019 Conflicts of interest: Joel Friedlander is president, chief medical officer, and co-founder of Triple Endoscopy, Inc. Joel Friedlander is listed as co- inventor on University of Colorado patents pending US 62/184,077, US/ 62/732,272, PCT/US2016/039352, AU201683112, CA 2,990,182, EU 16815420.1, JP 2017-566710, US 15/850,939, US 15/853,521, US15/887,438, US 62/680,798 039352 related to endoscopic methods and technologies. ' Grant Support: Red Cap Supported by NIH/NCRR Colorado CTSI Grant Number UL1 TR002535. RR is funded through the NIH R01 DK097112 and the Boston Children's Hospital Translational Research Program. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Anti-Myelin Oligodendrocyte Glycoprotein Antibody-Positive Optic Neuritis In A Girl With Ulcerative Colitis

No abstract available

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2018 AAP Murray Davidson Award - David Piccoli

No abstract available

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Alloimmunity and Cholestasis after Liver Transplantation in Children with Progressive Familial Intrahepatic Cholestasis

Objectives: Bile salt export pump (BSEP) deficiency is an important reason for chronic cholestasis leading to liver transplantation (LT) in early childhood. The underlying pathology is a dysfunction of BSEP due to various mutations in the ABCB11 gene. Cases of clinical recurrence after LT due to alloantibodies directed against BSEP (antibody-induced BSEP deficiency; AIBD) have been reported. Most of these patients could be controlled by intensified immunosuppression. Methods: We here report on three children with BSEP-deficiency and end-stage liver disease, which developed AIBD after LT refractory to extensive immunosuppressive and immunomodulatory treatments; retransplantation was necessary in all three patients. In one patient, a stem cell transplantation was performed successfully. Results: AIBD seems to be induced by triggering factors such as initial impaired graft function or infections after LT. Conclusion: The underlying mutation might play a role in this process. Intensifying immunosuppression may be able to control AIBD, but some cases seem to be refractory to treatment and require retransplantation. Stem cell transplantation may provide a new therapeutic option for cases refractory to conservative treatment. Address correspondence and reprint requests to D. Krebs-Schmitt, MD; Pediatric Gastroenterology and Hepatology; University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany (. e-mail: d.schmitt@uke.de). Received 23 May, 2018 Accepted 8 October, 2018 There are no conflicts of interest. There are no sources of funding. D. Krebs-Schmitt and A. Briem-Richter: Authors contributed equally. Conflicts of interest and Source of Funding: © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Cardiovascular Risk Assessment in Pediatric Liver Transplant Patients

Objectives: Cardiovascular (CV) diseases play a leading role in the mortality of adult liver transplant (LT) recipients. However, data regarding CV risk factors in children after LT remain sparse. The present study assessed the presence of CV risk factors and signs of CV impairment in LT children. Methods: A total of 42 LT recipients (21 males, age 9.93 ± 3.57 years) were studied. Body composition (body mass index SDS score, percentage of body fat (by bioimpedance analysis)), lipid profiles, glycemic control, blood pressure and arterial stiffness (assessed by aortic pulse wave velocity (PWV)) were evaluated. The effect of different treatment modalities (tacrolimus (TAC) (n = 30) or cyclosporine (CyA) (n = 11)) was also analyzed. Results: Almost eighteen % of children were overweight or obese. Patients on TAC had a significantly higher body fat mass and percentage of body fat compared with the CyA group (p 

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Decreased Fecal Calprotectin Levels in Cystic Fibrosis Patients After Antibiotic Treatment for Respiratory Exacerbation

Objectives: In all patients with cystic fibrosis (CF), gastrointestinal (GI) tract cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction occurs early in life. .The identical pathophysiological triad of obstruction, infection and inflammation causes disease of the airways and in the intestinal tract (CF enteropathy). Mucus accumulation within GI tract is a niche for abnormal microbial colonization, leading to dysbiosis. Fecal calprotectin (FC) is a neutrophil cytosolic protein released during apoptosis and necrosis and reflects inflammatory status. Systemic antibiotic treatment for pulmonary exacerbations has been shown to improve systemic inflammatory markers as well as serum and sputum calprotectin. Antibiotic treatment aimed at pulmonary complaints may improve GI tract inflammatory status. We hypothesized that high levels of fecal calprotectin present during pulmonary exacerbation are due, in part, to multi-organ dysbiosis and thus should diminish with systemic antibiotic treatment. Methods: This prospective pilot study enrolled 14 patients with CF, with no current GI symptoms. FC levels and lung function were measured at the beginning and end of systemic antibiotic treatment. Results: Compared to pre-antibiotic treatment baseline values, end of treatment FC levels declined significantly after antibiotic treatment, P = 0.004 and similarly, there was significant improvement in FEV1.0, P = 0.002. Conclusions: High levels of FC during respiratory exacerbation may reflect a systemic exacerbation rather than solely pulmonary. Antibiotic treatment lowered the FC levels possibly by its impact on the intestinal microbiome. Address correspondence and reprint requests to Zeev Schnapp, MD, Department of Pediatrics, Lady Davis Carmel medical center Michal 7 st., Haifa, Israel (e-mail: ZeevSc@clalit.org.il). Received 1 August, 2018 Accepted 20 October, 2018 The authors have declared that no competing interests exist. The authors received no specific funding for this work. The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Fecal Fat Concentration and Excretion in the First 2 Years of Life: a Cross-Sectional Study

Objectives: Data on pancreatic exocrine secretion in the youngest children are scarce. The aim of the study was to determine the range of normal values for fecal fat concentration (FFC) and fecal fat excretion (FFE) in infants and toddlers up to 2 years of age. Methods: 160 subjects aged 1–24 months (8 groups of 20: aged 1–3, 4–6 months, etc.) were included in the study. In all children, FFC (%) and FFE (g/day) were assessed in 3-day stool collection. Results: FFC correlated with age (r = -0.50, p 

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Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States

Objectives: : Nonalcoholic fatty liver disease (NAFLD) is common; however, no information is available on how pediatric gastroenterologists in the United States manage NAFLD. Therefore, study objectives were to: (1) understand how pediatric gastroenterologists in the US approach the management of NAFLD (2) identify barriers to care for children with NAFLD. Methods: : We performed structured one-on-one interviews to ascertain each individual pediatric gastroenterologist's approach to the management of NAFLD in children. Responses were recorded from open-ended questions regarding screening for comorbidities, recommendations regarding nutrition, physical activity, medications and perceived barriers to care. Results: : Response rate was 72.0% (486/675). Mean number of patients examined per week was 3 (standard deviation (SD) 3.5). Dietary intervention was recommended by 98.4% of pediatric gastroenterologists. Notably, 18 different dietary recommendations were reported. A majority of physicians provided targets for exercise frequency (72.6%, mean 5.6 days/week, SD 1.6) and duration (69.9%, mean 40.2 minutes/session, SD 16.4). Medications were prescribed by 50.6%. Almost one-half of physicians (47.5%) screened for type 2 diabetes, dyslipidemia, and hypertension. Providers who spent more than 25 minutes at the initial visit were more likely to screen for comorbidities (p = 0.003). Barriers to care were reported by 92.8% with 29.0% reporting ≥ 3 barriers. Conclusions: : The majority of U.S. pediatric gastroenterologists regularly encounter children with NAFLD. Varied recommendations regarding diet and exercise highlight the need for prospective clinical trials. NAFLD requires a multidimensional approach with adequate resources in the home, community, and clinical setting. Address correspondence and reprint requests to Jeffrey B. Schwimmer, MD, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, 3020 Children's Way, MC 5030 San Diego, CA 92123 (e-mail: jschwimmer@ucsd.edu). Received 2 May, 2018 Accepted 10 October, 2018 Grant Support: The project described was partially supported by the National Institutes of Health grants UL1TR000100 and UL1TR001442. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Disclosures: The authors have nothing to disclose Writing assistance: None. Author contributions: Warren L. Shapiro – Study concept and design; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Elizabeth L. Yu – Generation of data; collection of data; analysis and/or interpretation of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Jennifer Collins Arin – Study concept and design; assembly of data; administrative, technical or material support; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Karen Murray – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Sabina Ali – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Nirav Desai – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Stavra Xanthakos – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Henry Lin – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Naim Alkhouri – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Reham Abdou – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Stephanie Abrams – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Megan W. Butler – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Sarah Ann Faasse – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Lynette A. Gillis – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Timothy Ardell Hadley – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Ajay K. Jain – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Marianne Kavan – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Kattayoun Kordy – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Peter Lee – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Jennifer Panganiban – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript John Pohl – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Carol Potter – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Bryan Rudolph – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Shikha S. Sundaram – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Shivali Joshi – Assembly of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript James Proudfoot – Assembly of data; analysis and/or interpretation of data; statistical analysis; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Nidhi P. Goyal – Generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Kathryn E. Harlow – Generation of data; collection of data; analysis and/or interpretation of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Kimberly P. Newton – Study concept and design; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Jeffrey B. Schwimmer – Study concept and design; study supervision; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Transient Exocrine Pancreatic Insufficiency in Children: An Existing Entity?

Objectives: Pancreatic insufficiency in children is usually associated with diseases such as cystic fibrosis, Shwachman-Diamond syndrome, or chronic pancreatitis. Fecal elastase-1 is a reliable laboratory test for the diagnosis of exocrine pancreatic insufficiency (EPI). Transient pancreatic insufficiency has been rarely described and data on this entity are lacking in the medical literature. In this retrospective study we report 17 cases of transient pancreatic insufficiency presented mainly with failure to thrive and/or diarrhea. Methods: We followed 43 children (age range 1 month–18 years) with low fecal elastase-1 in our institution between the years 2009 and 2017. We followed growth and laboratory results (particularly, complete blood count, albumin, transaminases, celiac serology, sweat test, and fat-soluble vitamins). Elastase levels

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Application of Whole Exome Sequencing in Congenital Secretory Diarrhea Diagnosis

No abstract available

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Long-term Outcomes of an Interdisciplinary Tube Weaning Program: A Quantitative Study

Background and objectives: Children who become tube dependent need specialized treatment in order to make the transition to oral feeding. Little is known about long-term effects of tube weaning programs. This study analyses long-term effects (outcome, growth and nutrition data) in a large sample of formerly tube dependent children 1–6 years after participation in tube weaning programs, based on the "Graz model of tube weaning". Methods: Parents of children who completed a tube weaning program between 2009 and 2014 (N = 564) were asked to complete a questionnaire on their child's growth and nutrition. Data was analyzed using SPSS V22.0 for Windows (SPSS, Chicago, Illinois, USA). Results: Response rate was 47.16% (N = 266). Seven children had died between completion of the program and the long-term follow-up. 239 children (92.3%) were still exclusively orally fed 1–6 years after completion of the weaning program, 17 children (6.6%) were partially tube fed. Three children were completely tube fed (1.1%). Growth data showed no significant changes in zBMI between completion of weaning and long-term follow-up. Provided data on nutrition of fully orally fed patients showed that most children (N = 162, 68%) were eating an age appropriate diet, while a small percentage (N = 10, 4%) were fed with a high-caloric formula, a selective diet (N = 12, 5%) or a liquid/pureed diet (N = 55, 23%). Conclusion: Many children who undergo a tube weaning program based on the "Graz model of tube weaning" are able to stay on full oral feeds in the years after completion of the wean without deterioration of growth. Address correspondence and reprint requests to Dr. Sabine Marinschek, MSc, Medical University of Graz, Auenbruggerplatz 31, 8036 Graz, Austria (e-mail: sabine.marinschek@medunigraz.at). Received 27 June, 2018 Accepted 25 December, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Source of funding: None declared. Conflict of interest statement: none declared. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Adequate Infliximab Exposure During Induction Predicts Remission in Paediatric Patients With Inflammatory Bowel Disease

Objectives: Therapeutic drug monitoring has been proposed as a useful tool in the management of infliximab (IFX) treated patients with inflammatory bowel disease (IBD). The aim of this retrospective study was to determine whether IFX trough levels after induction therapy are predictive for outcome at week 52. Methods: All paediatric IBD patients receiving maintenance IFX at our centre, with IFX trough level available at their first maintenance infusion and a follow-up of at least 52 weeks were included. IFX induction regimens could be intensified at the discretion of the treating physician. All children received pro-active drug monitoring during maintenance with dose adaptation aiming to target a therapeutic window of 3–7 μg/mL. Results: We included 35 children (23 with Crohn's disease and 12 with ulcerative colitis). Median IFX trough levels just before the first maintenance infusion were significantly higher in children achieving clinical (4.6 μg/mL [2.7–11.8] versus 1.5 μg/mL [0.9–3.0]), biological (4.6 μg/mL [2.5–10.3] versus 2.6 μg/mL [0.3–3.2]) and combined clinical/biological remission (6.0 μg/mL [3.2–12.0] versus 2.6 μg/mL [1.1–3.2]) at week 52 compared to children not meeting these criteria (all p≤ 0.002). Binary logistic regression identified these trough levels as the only predictor for the same outcomes with an odds ratio (95%CI) of 2.083 (1.085- 3.998), 2.203 (1.101- 4.408) and 2.264 (1.096- 4.680), respectively (all p 

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MCH Workforce Capacity: Maximizing Opportunities Afforded by a Changing Public Health System

Abstract

Objectives A skilled workforce is essential to advancing maternal and child health (MCH) in a rapidly changing public health system. Little is known about the MCH workforce's existing capacity to maximize opportunities afforded by ongoing change. We assessed MCH workforce capacity in three areas: Systems Integration, Evidence-Based Decision-Making, and Change Management/Adaptive Leadership. We then examined associations between workforce capacity and modifiable workforce development strategies/resources. Methods Data are from the Public Health Workforce Interests and Needs Survey (PH WINS). The present study was limited to employees working in MCH programs (weighted N = 3062). Workforce capacity was operationalized as self-reported awareness of public health trends and proficiency to perform related skills in the three areas. Survey-weighted generalized estimating equations were used to fit logistic regression models accounting for employee clustering within states. Results While awareness of public health trends was low, the majority of employees (> 70% in each area) reported proficiency to perform skills related to these trends. Capacity was lowest in Systems Integration. Employee engagement in academic partnerships and higher state contributions to MCH program budgets were the strategies/resources most consistently associated with higher capacity. Workplace support was the strongest correlate of capacity in Change Management/Adaptive Leadership. Conclusions for Practice Although employees lacked familiarity with specific public health trends, they were proficient in skills needed to engage in related work. Still, areas for improvement remain. Results provide a baseline against which future training efforts can be evaluated. Academic partnerships and MCH program funding may be useful to prioritize in the context of health transformation.

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Craniovertebral Junction and Spine

EDITORIALS
	From "only decompression" to "only fixation:" A century-long journey of surgical treatment for spinal spondylosis	p. 219
	Atul Goel DOI:10.4103/jcvjs.JCVJS_118_18
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	Suboccipital pain in Chiari formation: Its cause and significance	p. 221
	Atul Goel DOI:10.4103/jcvjs.JCVJS_117_18
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ORIGINAL ARTICLES
	Preliminary results of anterior cervical arthroplasty by porous alumina ceramic cage for cervical disc herniation surgery	p. 223
	Keyvan Mostofi, Babak Gharaei Moghaddam, Morad Peyravi, Reza Karimi Khouzani DOI:10.4103/jcvjs.JCVJS_95_18   Objective: Anterior cervical arthroplasty (ACA) is the gold standard surgery in severe or unresponsive cases of cervical disc herniation, uncarthrosis, and foraminal stenosis. The aim of this study is to establish the impact and outcome evaluations of managing the patients operated for cervical arthroplasty by the intersomatic porous alumina ceramic cervical cages (PACC). The authors describe their experience in the area to allow the comparison of effectiveness of ceramic cages versus other interbody fusion cages. Materials and Methods:Between April 2015 and September 2018, we operated 118 for ACA by using PACC. Among them, 52 were female and 66 were male, with an average age of 46.78 years. Results: The mean symptoms duration was 14.1 months. The most frequent level of the disorder was C5–C6 followed by C6–C7 level. Mean follow-up was 3.3 years. The Neck Disability Index (NDI) and the visual analog scale (VAS) were used to evaluate the patients status. No significant differences were observed between our results and literature data regarding operative time, duration of hospitalization, and NDI; however, we observed a shorter period and higher rate of bony fusion. Conclusion: The results from the present study corroborate that implementing of PACC is a good alternative treatment for the patient operated by ACA for cervical disc herniation or foraminal cervical stenosis.
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	Timing for surgical intervention in DISHphagia	p. 227
	Waeel Ossama Hamouda DOI:10.4103/jcvjs.JCVJS_83_18   Introduction: Dysphagia in old patients secondary to diffuse idiopathic skeletal hyperostosis (DISH) syndrome is underdiagnosed. Surgical resection of the offending osteophytes is the definitive treatment. However, the timing of surgery in the course of the disease is still controversial. The study tries to find a correlation if any, between the timing of osteophytectomy surgery aimed to relieve DISH syndrome-induced dysphagia and the surgical outcome.Methods: During the period from 2010 to 2015, clinical and radiological data of patients who presented with dysphagia attributed to DISH syndrome were retrospectively reviewed along with their management and outcome.Results: One female and seven male patients were included in the study. Mean age was 71 years. Mean duration of dysphagia was 3 years and 10 months. Surgical resection was attempted through anterolateral cervical approach in five cases who were fit for surgery, in which four showed complete resolution of dysphagia (one experienced transient hoarseness of voice for 4 weeks postoperatively), and the fifth showed minimal improvement after limited resection due to intraoperative finding of marked esophageal adherence to osteophytes. The two unfavorable outcomes (subtotal resection and transient hoarseness of voice) occurred in relatively older patients (average: 75.5 years) with longer standing dysphagia (average: 7 years). Conclusion: DISH syndrome as a cause of dysphagia is commonly underlooked. Surgical resection of the offending osteophytes through an anterolateral approach is a safe and effective procedure. For patients who are fit for surgery, older age or longer duration of dysphagia might be associated with less favorable surgical outcome.
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	Who benefits more in osteoporotic fractures: Pedicle screw instrumentation or kyphoplasty for American Society of Anesthesiologists II/III patients?	p. 232
	Tjark Tassemeier, Marcel Haversath, Moritz Schutzbach, Marcus Jäger DOI:10.4103/jcvjs.JCVJS_55_18   Purpose: Osteoporotc fractures with posterior wall injury are commonly treated with a pedicle srcrew instrumentation (PSI) or a ballonkyphoplasty (BKP). A predictor for complications for these patients is the American Society of Anesthesiologists (ASA) class. Clinical results in ASA II/III patients who underwent BKP and PSI due to OF were evaluated to find the optimal treatment regimen. Materials and Methods: In a retrospective study design, ASA Class II and III patients with OF type OF 2 and OF 3 according to the German Society of Orthopedics and Trauma Surgery classification who underwent surgery between 2011 and 2016 were enrolled. Perioperative data such as time of surgery, cement leakage, adjacent level fractures, screw loosening, wound infections, and segmental kyphosis correction were measured and a statistical analysis was conducted. Results:Ninety-nine patients met the inclusion criteria, 17 were classified as ASA II and 82 patients were classified as ASA III. Twenty-eight individuals were treated by PSI, whereas 71 underwent BKP. Not only a longer average operation (120 min) and hospital stay (21 days) were documented in the PSI group but also a better kyphosis correction (7.5°). In comparison, the BKP group required an average operation time of 35.5 min with a mean kyphosis correction of 2.1°. A statistical analysis revealed the surgical procedure and not the ASA class to be a relevant factor for complication and revision surgery. Conclusions: BKP is a safe and effective therapy including also fractures with posterior wall defects while PSI showed advantages in restoring the sagittal realignment but higher complication and revision risk.
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	Lumbar disk herniation: How far should efforts go to minimally invasive procedure?	p. 238
	Keyvan Mostofi, Babak Gharaei Moghadam, Morad Peyravi, Reza Karimi Khouzani DOI:10.4103/jcvjs.JCVJS_70_18   Background: Minimally invasive surgery (MIS) of lumbar disk herniation allows avoiding less of a mess in crossing structures, reducing muscular and cutaneous scarring, postoperative pain, lengthy recovery times, and the rate of infection. The aim of this study is to explain our experience in MIS of disc herniation. We compare the outcome of three different surgical techniques used for the treatment of lumbar disc herniation. Materials and Methods: A total of 1147 patients have been operated from July 2008 to December 2015 for lumbar disk herniation by posterior endoscopic approach. Three hundred and seventy-nine patients underwent discectomy and herniectomy (DH), 557 patients have been operated by herniectomy (H), and 211 patients underwent only bone decompression (BD). Results: The results show 80.10%, 82.06%, and 84.02% excellent outcome, respectively, in BD, DH, and BD techniques. Conclusion: Analysis of the data demonstrates that the results obtained are equivalent and comparable in different used techniques for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way.
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	Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries	p. 241
	Adam R Dyas, Thomas E Niemeier, Gerald Mcgwin, Steven M Theiss DOI:10.4103/jcvjs.JCVJS_81_18   Objective: The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD). Materials and Methods: Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa. Results: Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62). Conclusion: The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.
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	On the linear sizes of vertebrae and intervertebral discs of children in the beginning of puberty	p. 246
	Mikhail Dudin, Yuri Baloshin, Igor Popov, Nikita Lisitsa, Stepan Bober DOI:10.4103/jcvjs.JCVJS_91_18   Study Design: We collected experimental data concerning vertebrae sizes and performed an investigation of these data for different patient ages by methods of mathematical statistics. Purpose: The standard dimensions of vertebrae and intervertebral discs are of major importance for obtaining a comprehensive understanding of spine diseases and their successful treatment. The purpose is to study these sizes for children at the age of 9–14 years.Overview of Literature: Unfortunately, this issue is poorly presented in the corresponding literature. There are no systematic results. Only particular cases are presented. Materials and Methods: Experimental is based on the: results of X-ray investigations of children spines. Theoretical background is given by methods of mathematical statistics. Results: Systematic description of vertebrae sizes for children of age 9–14 is given. This specific age interval is the most common period of initiation of various pathological deformations of human spine.Conclusions: The acquired data both reflect the process of spine growth and can serve for building correct mathematical models of a healthful or diseased spine.
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	A novel technique for the subfascial insertion of magnetically controlled growing rods – The Alder Hey technique	p. 250
	Sudarshan Munigangaiah, Phil Brown, Mohamed Mohamed, Colin E Bruce, Jayesh M Trivedi, Neil T Davidson DOI:10.4103/jcvjs.JCVJS_105_18   Purpose: In this study, we would like to describe a novel technique for subfascial insertion of magnetically controlled growing rods using chest drain during surgery for early-onset scoliosis. Materials and Methods:Posterior approach, surgical dissection to the spine is performed exposing the relevant anatomy to allow placement of pedicle screws always in the distal construct and pedicle screws or hooks in the proximal construct. To allow easy passage of the Magnetic Expansion Control (MAGEC) rod, as well as easy maneuvering of the rod in either the cranial to caudal direction, we use a chest drain of size 24 French diameter as a tunnel. This allows surgeons to fit the nonflexible part of MAGEC rod in the middle of the deformity and cut to length passed through the chest drain from a cranial to caudal position and then chest drain is removed. Results: A total of 40 children with early-onset scoliosis had insertion of MAGEC rods using this technique. There were 21 female and 19 male patients. Early-onset scoliosis etiology is idiopathic in 20 patients, neuromuscular in 16 patients, and others in 4 patients. Median age across all groups was 7 years (range 4–13) at the time of surgery. Follow-up ranged from 11 to 56 months with a median of 24 months. Conclusion: The use of a chest drain during subfascial passage of magnetically controlled growing rod is a safe, reliable, reproducible novel technique. This shortens overall time of surgery in our experience.
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	Clinical and radiological union rate evaluation of type 2 odontoid fractures: A comparison between anterior screw fixation and halo vest in elderly patients	p. 254
	Massimo Girardo, Alessandro Rava, Giosuè Gargiulo, Angela Coniglio, Stefano Artiaco, Alessandro Massè, Federico Fusini DOI:10.4103/jcvjs.JCVJS_93_18   Purpose: Odontoid fracture is a very common cervical injury, especially in elderly patients. Despite the high frequency, the appropriate management is still debated. The aim of this study is to evaluate clinical and radiological outcomes after anterior screw fixation or halo vest (HV) in type II odontoid fracture in elderly patients.Materials and Methods: Between January 2013 and December 2015, 135 consecutive patients affected by odontoid process were found. According to inclusion and exclusion criteria, 57 patients were included in the study. Patients were evaluated with visual analog scale (VAS), Smiley–Webster Scale (SWS), Italian Version of the Neck Disability Index (NDI), and patient satisfaction during follow-up. Furthermore, radiological data were evaluated for bone healing. Student's t-test or Fisher's exact test was used between groups, analyzing radiological and clinical results, and level of statistical significance was set at P < 0.05. Results: Seventeen patients were female and 40 were male. Twenty-seven patients were included in surgical group (SG) while 30 were included in HV group with a mean follow-up of 37.74 ± 10.52 months. A significant difference (P < 0.05) between groups was found for pseudoarthrosis, with a lower rate for SG. No significant differences in term of VAS, NDI, and SWS were found between groups (P > 0.05); SG reached higher satisfaction than HV group (P = 0.0271). Conclusions: Both treatments are equivalent in terms of clinical outcomes, and they are a valuable choice in the management of type II odontoid fracture. However, it must be considered that patients could slightly tolerate HV and may need a change of treatment.
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	Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis	p. 260
	Alessandro Landi, Giovanni Grasso, Cristina Mancarella, Demo Eugenio Dugoni, Fabrizio Gregori, Giorgia Iacopino, Harrison Xiao Bai, Nicola Marotta, Andrea Iaquinandi, Roberto Delfini DOI:10.4103/jcvjs.JCVJS_94_18   Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as "other" was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ2 < 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence.
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CASE REPORTS
	The repair using a fibular graft of cervical vertebral collapse due to renal cell carcinoma: Late results with a case report	p. 267
	Vaner Koksal, Hüseyin Eren, Hasan Güçer DOI:10.4103/jcvjs.JCVJS_32_18   The most common cause of spinal tumors is metastases, but the cervical vertebra is the least common region of spinal metastasis, and relatively, little is published about surgery in metastasis to the cervical vertebra. While spinal metastasis is most often caused by neoplasms originating from the lung, breast, and prostate, renal cell carcinoma (RCC) metastasis is very rare. A 47-year-old patient introduced here presented with severe pain spontaneously on his neck and in his arm. In the radiology of the patient without neurological deficit, a pathologic vertebral collapse was detected in the C6 vertebral corpus. The patient underwent anterior cervical corpectomy. The fibula graft taken from his right leg was implanted in the emptied area and supported by an anterior plaque, and restoration of physiological cervical lordosis was established. From the pathological tissue that was taken, it was determined that the cause of the lysis was an RCC metastasis. After surgical repair of the cervical spine, a primary pathology with a diameter of 10 cm was detected in the patient's kidney, and a radical nephrectomy was performed. After 6 years of follow-up, there was no recurrence, and the patient continued his normal daily life. Radiologically between the autologous fibula graft and its own vertebral body was observed to achieve very good fusion. In this study, we emphasized the importance of resection of metastasis together with a primary tumor in a metastatic RCC case to cure the patient and provide the desired quality of life.
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	Transthoracic approach for ventrally situated paraspinal extradural hydatid cyst of the dorsal spine	p. 271
	Mohnish P Dighe, Srikant Balasubramaniam, Trimurti D Nadkarni DOI:10.4103/jcvjs.JCVJS_71_18   A 40-year-old female presented with back pain without any neurological deficits. Radiological investigations revealed a ventrally situated paraspinal lesion causing widening of the right D4 neural foramen. She underwent a right posterolateral thoracotomy and excision of the lesion in toto, which was reported as a hydatid cyst on histology. Ventrally situated paraspinal extradural hydatid cysts are rare. A Transthoracic surgical exposure offers a direct approach for complete excision of the lesion, minimizing the chances of rupture and spillage.
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	Autostabilization of neglected high-grade fracture–dislocation in the cervical spine	p. 274
	Kunal Shah, Akshay Gadiya, Abhay Nene DOI:10.4103/jcvjs.JCVJS_92_18   Neglected cervical spine trauma is rare with very few case series reported in literature. There are no clear guidelines for its treatment. If operative treatment is sought, the role of skull traction, type of approach (anterior only, posterior only, or combined), sequence of surgery, type of instrumentation, etc., have to be considered. Hence, the treatment is challenging. Autostabilization has been described in the natural history of degenerative lumbar spondylolisthesis. As a result, many patients are treated nonoperatively, obviating need of surgery. We report two cases of neglected/untreated fracture–dislocation at subaxial cervical spine. They presented with exertional neck pain. Computed tomography scan showed bony fusion at involved level. The patient was treated nonsurgically with favorable outcome at long-term follow-up. Our cases depict autostabilization in a case of neglected traumatic cervical spine injury, which is never been reported. Such patients do well with nonsurgical treatment, thus obviating need for extensive deformity correction.
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	Performing the screw fixation from C3 to odontoid process in a patient with Klippel-Feil syndrome and type II odontoid fracture	p. 277
	Mustafa Ogden, Ulas Yuksel, Ibrahim Akkurt, Bulent Bakar DOI:10.4103/jcvjs.JCVJS_54_18   A 56-year-old female patient was admitted with a history of pain during neck movements after cervical injury. Computerized tomography scan revealed type II odontoid fracture and fusion anomaly between C2 and C3 vertebrae. At surgery, the anteroinferior part of C2 vertebra corpus could not be reached; therefore, transodontoid screw was advanced from C3 vertebra toward odontoid process. At follow-up examination, the complaints of the patient had recovered, and fracture line was completely fused. Advancing screw from C3 to odontoid process via anterior cervical approach could be thought an alternative treatment option in the patient with short neck caused from vertebra fusion anomaly and/or obesity.
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	Unprecedented complication of odontoid regeneration after transoral odontoidectomy	p. 280
	Manish Garg, MS Sridhar, Saurabh Verma, Jitendra Bhadoria DOI:10.4103/jcvjs.JCVJS_98_18   Transoral odontoidectomy followed by occipitocervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction. Despite the large amount of literature on this approach and its complications, odontoid process regeneration and causing the worsening of symptoms of brainstem dysfunction and upper cervical cord were not found in the English literature. We report the case of odontoid regeneration in a 12-year-old girl. She presented with torticollis and symptoms of brainstem dysfunction and upper cervical cord compression with syringohydromyelia and underwent transoral resection of dens and posterior occipitocervical fusion at the age of 7 years. Post surgery, clinically and radiologically, the resolution was evident till the age of 11 years when the child started to have relapse and worsening of the previous symptoms. The computed tomography/magnetic resonance imaging shows regeneration of the odontoid process compressing the brain stem with an increase in syringohydromyelia. We suggest that there is a need for the removal of the complete odontoid process with periosteum and also beyond the dentocentral synchondrosis to prevent late recurrences of odontoid regeneration.
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	Isolated enchondroma of the atlas	p. 283
	Necati Ucler DOI:10.4103/jcvjs.JCVJS_101_18   Periosteal enchondromas located in the spine are rare. We reported an even more infrequent occurrence of a periosteal enchondroma in the cervical spine of a 19-year-old girl. During the operation, a giant (>8 cm × 5.5 cm × 5 cm) ossified periosteal enchondroma with involvement of posterior structures and muscles of the axis was resected. The pathological examination revealed that the tumor consisted of enchondroid tissue with typical chondrocytes, confirming the diagnosis of periosteal enchondroma. Early identification of the initial lesion should be coupled with total surgical resection, as a definitive treatment, to prevent malignant transformation. Enchondromas grow in an expanding manner which makes easy total resection.
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LETTER TO EDITOR
	Giant cell glioblastoma with spinal and spinal leptomeningeal metastasis in a child: A rare presentation of a rare tumor	p. 286
	Mahmood Dhahir Al-Mendalawi DOI:10.4103/jcvjs.JCVJS_97_18
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