Objectives The purpose of this study was to assess the frequency of very late stent thrombosis (VLST) after stenting with bare-metal stents (BMS) and drug-eluting stents (DES) for ST-segment elevation myocardial infarction (STEMI). Background Stent thrombosis occurs more frequently after stenting for STEMI than after elective stenting, but there are little data regarding VLST. Methods Consecutive patients (n = 1,463) who underwent stenting for STEMI were prospectively enrolled in our database. BMS were implanted exclusively from 1995 to 2002, and DES and BMS were implanted from 2003 to 2009. Follow-up was obtained at 1 to 15 years. Results Bare-metal stent patients (n = 1,095) were older and had more shock, whereas DES patients (n = 368) had more diabetes and smaller vessels. Stent thrombosis occurred in 107 patients, of which 42 were VLST (>1 year). Stent thrombosis continued to increase to at least 11 years with BMS and to at least 4.5 years with DES. Stent thrombosis rates with BMS versus DES were similar at 1 year (5.1% and 4.0%, respectively) but increased more with DES after the first year (1.9%/year vs. 0.6%/year, respectively). Landmark analysis (>1 year) found DES had a higher frequency of VLST (p < 0.001) and reinfarction (p = 0.003). Drug-eluting stent was the only significant independent predictor of VLST (hazard ratio: 3.79, 95% confidence interval: 1.64 to 8.79, p = 0.002). Conclusions Very late stent thrombosis after primary PCI for STEMI occurs with relatively high frequency to at least 11 years with BMS and to at least 4.5 years with DES. Very late stent thrombosis and reinfarction (>1 year) were more frequent with DES. New strategies are needed to manage this problem.

Objectives: There are increasing concerns regarding proton pump inhibitor (PPI) use and the risk of fractures in adults. Few studies have evaluated this risk among pediatric patients. This study examined fractures and fracture location among pediatric patients exposed to PPI compared with those without documented exposure. Study Design: Encounters for patients 6 months to 15.5 years were identified between July 1, 2011 to December 31, 2015 in the Pediatric Hospital Information System database. Exclusion criteria was applied for chronic illnesses, conditions or medications predisposing to fracture. Encounters were classified as PPI encounters if a charge for PPI was documented. PPI encounters were propensity matched to non-PPI encounters. Following initial encounter, patients were evaluated over a 2-year period for hospitalizations resulting from fracture. Results: There was a statistically significant higher rate of fractures among the PPI-exposed group (1.4% vs 1.2%, P = 0.019). Adjusting for remaining differences in sex, race, encounter type, payer, and resource intensity after matching, the difference remained statistically significant (P = 0.017) with an adjusted odds ratio (95% CI) of 1.2 (1.0--1.4). Upper extremity was the most common location for fracture; however, the PPI cohort was more likely to suffer from lower extremity, rib, and spinal fractures (P = 0.01). Conclusions: This study suggests an increased risk of fracture among pediatric patients taking PPI. Among patients hospitalized with a fracture, those with PPI exposure had a higher rate of lower extremity, rib, and spine fractures compared with controls. This appeared to be a class effect not related to individual PPI agent.

Purpose: The Oral-anal Transit Test (OTT) is a simple method of obtaining information about colonic transit. We aim to assess the correlation of OTT with the neuromuscular integrity of the colon determined by colonic manometry (CM). Methods: All patients who had OTT followed by CM were evaluated. Less than 6 of 24 markers remaining on OTT was considered normal. CM was performed per previously published guidelines. A normal CM was defined as at least one High Amplitude Propagating Contraction progressing from the most proximal sensor through the sigmoid colon. Results: A total of 34 patients underwent both OTT and CM (44% male, age 4-18 years, mean 11.5 years, 97% functional constipation +/− soiling, Hirschsprung's Disease). Of normal and abnormal OTT patients, 85.7% (6/7) and 18.5% (5/27) respectively had normal CM. When all markers progressed to at least the sigmoid colon, this was 100% predictive against colonic inertia. Greater than 50% of patients with manometric isolated sigmoid dysfunction had markers proximal to the recto-sigmoid. Conclusion: OTT and CM are both valuable studies that assess different aspects of colonic function. OTT can be used as a screening test to rule out colonic inertia. However, the most proximal extent of remaining markers does not predict the anatomical extent of the manometric abnormality, particularly in isolated sigmoid dysfunction.

Torsion of an accessory spleen is an exceedingly rare cause of abdominal pain in pediatric patients. The diagnosis is frequently challenging as presentation is variable and diagnostic imaging can be aspecific. The current case describes an unusual presentation of a torted accessory spleen in a 5-year-old girl with biliary atresia splenic malformation syndrome who initially presented with non-specific abdominal symptoms and fever. The diagnosis was made following fine-needle aspiration of a suspected intraabdominal abscess. The case highlights the diagnostic challenge of accessory splenic torsion and stresses the importance of its inclusion on the differential diagnosis of pediatric patients, especially those with known splenic or laterality abnormalities, presenting with both acute and sub-acute abdominal symptoms.

Background: Iron deficiency anemia (IDA) is common in the pediatric population with high risk factors such as nutritional deficiency, inflammatory bowel disease (IBD) and other bowel inflammatory disorders, menorrhagia, blood loss, poor absorption and anemia of chronic disease. Intravenous (IV) iron supplementation has become a more desirable mode of treatment in patients with moderate to severe anemia and in patients who are either unresponsive to or have undesirable side-effects secondary to oral iron. Iron sucrose and Iron dextran have been traditionally used in pediatrics as they both are FDA approved for use in this population. Ferric carboxymaltose (FCM) has only been FDA approved for use in adults however is currently used in pediatrics as well. One of the major advantages of Ferric carboxymaltose is the ease of dosing and efficacy. Though FCM was approved for adults in 2013 and there have been no safety concerns, it is not yet FDA approved for pediatric patients despite a few pediatric studies demonstrating its safety and efficacy (Laass, et al., 2014; Powers et al., 2017; Tan et al., 2017, Carman et al., 2019). The purpose of this study is to examine the utilization of different IV iron formulations in a large pediatric hospital as well as evaluate the safety and efficacy of ferric carboxymaltose in comparison to other IV iron formulations. At this time, we present data regarding the use of different forms of IV iron. Methods: This is a retrospective chart review study of all patients who met inclusion criteria in a large pediatric hospital who received Iron dextran, Iron sucrose, and/or FCM between the dates of 8/1/2018 through 9/30/2019. Anonymized data from eligible patients was entered into a secure electronic database. Once our population of interest was isolated, based on the proposed criteria, we reviewed charts individually and collected data including demographics and details about each IV iron administration. Demographic data encompassed race and gender. We also recorded the patients' underlying diagnosis (or diagnoses) contributing to iron deficiency anemia. In addition to compiling demographic data, we also wanted to analyze the trend of IV iron usage in our institution. This was done by tallying the number of each type of IV iron infusion monthly for the allotted time period. Results: A total of 120 patients met inclusion criteria and were included in this study with details regarding diagnosis in Figure 1. Fifty-six (46.7%) patients were male and 64 (53.3%) were female. We also analyzed the underlying diagnoses leading to IDA of patients who received IV iron infusions. Most patients had an underlying IBD diagnosis (Crohn's Disease 49.2%, Ulcerative colitis 15.8%, and Indeterminate colitis 5.8% of all included patients). Additional diagnoses included 18 patients (15%) with nutritional IDA and 8 patients (6.7%) with heavy menses. Examples of "other" diagnoses are blood loss secondary to immune thrombocytopenia, short bowel secondary to complex gastroschisis, gastrointestinal bleed secondary to Helicobacter pylori, short bowel secondary to bowel resection due to graft versus host disease after hematopoietic stem cell transplant, TMPRSS6 mutation, protein losing enteropathy, short bowel secondary to midgut volvulus and intestinal atresia, among other diagnoses. We also analyzed the overall usage of IV iron in our institution during this same time period. The number of IV iron infusions has steadily increased since August 2018. The average number of IV iron infusions was 18 per month in 2018 and 22.67 per month in 2019. As shown in figure 3, the utilization of iron dextran has decreased over time. The graph also displays that the usage of FCM at our institution continues to increase as time progresses. Conclusion: Analysis of demographic data reveals that an underlying gastrointestinal diagnosis is the most common reason for receiving IV iron likely due to decreased absorption of enteral iron. Our data has also shown that the overall usage of IV iron is increasing in the pediatric population as well as specifically FCM. This study is the first retrospective pediatric review comparing the utilization of different IV iron formulations including FCM. Preliminary data demonstrates an increase in hemoglobin after treatment with FCM, however further analysis of the data is ongoing. Figure 1 Disclosures No relevant conflicts of interest to declare.