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When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events., (© 2023. Springer Nature Limited.)

A monocular 22-year-old man with recalcitrant familial exudative vitreoretinopathy presented with progressive subretinal lipid exudation and lipid maculopathy that responded poorly to repeated aflibercept injections. The subretinal exudation started temporally and gradually progressed, involving the macula and the retinal periphery in all 4 quadrants. At the 22-month follow-up visit, macular and peripheral subretinal exudation persisted despite a total of 29 injections. Faricimab was then injected once every 2 weeks for a total of 3 injections, which resulted in rapid dramatic resolution of the macular and most of the peripheral subretinal exudation. No ocular or systemic adverse events were noted. [ Ophthalmic Surg Lasers Imaging Retina 2023;54:426-428.] .

Purpose: Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation., Methods: A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups., Results: During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups., Conclusions: Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: There is wide practice variation in the use of laparoscopic fundoplication (LF) versus gastrojejunostomy (GJ) tube insertion for children who do not tolerate gastric feeds. Using weight gain as an objective proxy of adequate nutrition, we sought to evaluate the difference in weight gain between LF and GJ., Methods: A retrospective, cohort study was conducted of patients ≤ 2 years who underwent LF or GJ between 2014 and 2019 at a single institution. Patient characteristics, change in weight 1-year post-procedure and frequency of unplanned healthcare utilization encounters were collected and examined., Results: A total of 125 patients (50.4%LF, 49.6%GJ) were identified. Adjusted modeling demonstrated that on average, there was an additional 0.85-unit increase in weight-for-age Z scores in the LF compared to the GJ cohort (p = 0.01). The GJ cohort had significantly more unplanned healthcare utilization encounters (4.2, SD 3.4) compared to LF (3.0, SD 3.1) (p = 0.03). Furthermore, the GJ cohort underwent an average of 3.3 planned GJ exchanges within 1-year post-procedure., Conclusion: In the first year post-operatively, LF is associated with increased weight gain and fewer unplanned and overall healthcare encounters compared to GJ. Long-term outcomes including weight gain and quality-of-life measures should be studied to develop standardized guidelines for this common clinical scenario., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Neovascular Glaucoma (NVG) is a condition normally caused by hypoxic posterior ocular disease, which produces angiogenic factors such as vascular endothelial growth factor (VEGF) that stimulate new vessel proliferation of the anterior segment and angle, eventually leading to angle closure, reduced outflow of aqueous humor and increased intraocular pressure. Without treatment elevated intraocular pressure can rapidly progress to loss of vision. Treatment includes addressing the intraocular pressure and reducing the ischemic drive with panretinal photocoagulation (PRP) of the ischemic retina. Recent imaging advancements allow for ultra-widefield fluorescein angiography (UWFA) which expand the amount of peripheral retina that can be evaluated for non-perfusion. Here we aim to study patterns of non-perfusion in NVG using a group of PRP naïve patients with recent onset NVG., Methods: This study is a retrospective single-center cross-sectional study of patients seen at LAC + USC Medical Center from January 2015 to April 2020 with new onset NVG, without PRP and with UWFA completed. The percentage of ischemic index of the retina was calculated from the UWFA and evaluated in three distinct zones centered on the fovea: the posterior pole, the mid periphery, and far periphery. To increase sample size, a confirmatory group was included, with PRP allowed prior to UWFA but not before diagnosis. In addition, the time between diagnosis and UWFA was increased to 6 months., Results: A total of 11 eyes met inclusion criteria for the primary group. Ischemic index was found to be 91% in the far periphery, 77% in the mid periphery, and 42% at the posterior pole. The total average ischemic index was 76%. There was a statistically significant difference between the far periphery and posterior pole and mid periphery and posterior pole. A total of 24 eyes met criteria for the confirmatory group. Ischemic index for the confirmatory group was found to be 93% in the far periphery, 75% in the mid periphery, and 35% at the posterior pole. There was a statistically significant difference between the far periphery, posterior pole and mid-periphery., Conclusion: This knowledge can be used to further guide treatment and understand risk for NVG., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s). Published by IMR Press.)

Purpose: 1.7 billion children lack access to surgical care, particularly in low- and middle-income countries (LMIC). The pediatric surgical workforce density (PSWD), an indicator of surgical access, correlates with survival of complex pediatric surgical problems. To determine if PSWD also correlates with population-level health outcomes for children, we compared PSWD with pediatric-specific mortality rates and determined the PSWD associated with improved survival., Methods: Using medical licensing registries, pediatric surgeons practicing in 26 countries between 2015 and 2019 were identified. Countries' PSWD was calculated as the ratio of pediatric surgeons per 100,000 children. The correlation between neonatal, infant and under 5 mortality rates and PSWD was assessed using Spearman's correlations and piecewise linear regression models., Results: Four LIC, eight L-MIC, ten UMIC and four HIC countries, containing 420 million children, were analyzed. The median PSWD by income group was 0.03 (LIC), 0.12 (L-MIC), 1.34 (UMIC) and 2.13 (HIC). PSWD strongly correlated with neonatal (0.78, p < 0.001), infant (0.82, p < 0.001) and under 5 (0.83, p < 0.001) mortality rates. Survival improved with increasing PSWD to a threshold of 0.37., Conclusion: PSWD correlates with pediatric population mortality rates, with significant improvements in survival with PSWD > 0.37. Currently, PSWD in LMICs is inadequate to meet UN Sustainable Development Goal 3.2 for child mortality., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To characterize the relationship between mean and sectoral variation of anterior chamber angle (ACA) width using anterior segment optical coherence tomography (AS-OCT)., Methods: Subjects aged 50 years or older were identified from the Chinese American Eye Study (CHES), a population-based epidemiological study in Los Angeles, CA. Each subject underwent a complete ocular examination including gonioscopy and AS-OCT imaging. Primary angle closure disease (PACD) was defined as inability to visualize pigmented trabecular meshwork in 3 or more quadrants. Four AS-OCT images from one eye per subject were analyzed and parameters describing ACA width were measured at 500 and 750 μm from the scleral spur: angle opening distance (AOD), trabecular iris space area (TISA), and scleral spur angle (SSA). The relationship between mean and sectoral variation of ACA width was assessed using locally-weighted scatterplot smoothing (LOWESS) regression and change-point analyses and Spearman correlation coefficients., Results: 674 eyes (337 with PACD, 337 without PACD) from 674 subjects were analyzed. Overall, sectoral variation of ACA width decreased as mean ACA width decreased. This relationship was divided into two phases based on the change-point analysis. Sectoral variation of ACA width was strongly and significantly correlated (P < 0.001) with mean ACA width with below parameter-specific change points for most parameters: AOD500 (r = 0.599), AOD750 (r = 0.246), TISA500 (r = 0.734), TISA750 (r = 0.664), SSA500 (r = 0.661), SSA750 (r = 0.394). Correlations were weaker but still significant (P < 0.004) above these change points for most parameters: AOD500 (r = 0.321), AOD750 (r = 0.550), TISA500 (r = 0.122), TISA750 (r = 0.275), SSA500 (r = -0.036), SSA750 (r = 0.313). Correlations to the left and right of the change points strengthened when sectoral variation of ACA width was adjusted for mean ACA width., Conclusions: Correlations between mean and sectoral variation of ACA width strengthen as the severity of angle narrowing worsens. This relationship likely reflects anatomical changes related to chronic angle closure and may be relevant for refining current definitions and management of PACD.

Anterior segment optical coherence tomography (AS-OCT) is a non-contact imaging technique that produces high-resolution images and quantitative measurements of the anterior segment and its anatomical structures. There has been rapid development of OCT technology over the past 2 decades, with the transition from time-domain to Fourier-domain OCT devices. By integrating these advancements in OCT technology, AS-OCT devices have evolved into versatile clinical and research tools for studies of the anterior segment and ocular surface. The primary purpose of this article was to review OCT technology and AS-OCT devices as well as applications of AS-OCT for clinical practice and scientific research. We first describe the different types of OCT technology, how they have been adapted for AS-OCT imaging, and differences between various AS-OCT devices. We then review the applications of AS-OCT for characterizing the anatomical structures of the anterior segment and aqueous outflow pathways, including the anterior chamber angle, trabecular meshwork, and Schlemm canal. We also describe glaucoma-related applications of AS-OCT imaging, which include evaluating patients for static and dynamic biometric risk factors of primary angle closure disease and assessing the efficacy of glaucoma interventions, such as laser peripheral iridotomy and glaucoma surgery. Finally, we review other clinical applications of AS-OCT imaging for detection and management of diseases of the ocular surface, cornea, and lens., (Copyright © 2019 by Asia Pacific Academy of Ophthalmology.)

Many children with disabling conditions do not acquire the skills to successfully ride a 2-wheeled bicycle. The aim was to describe cycling patterns before and after an innovative learn-to-ride bike camp and factors that facilitate or hinder the generalization of skills developed at camp to home. Parents and children participated in semistructured interviews 3-4 mo postcamp. Transcripts were examined deductively for participation and contextual influences using a template of codes approach. None of the children were successfully riding a 2-wheeled bicycle before camp. Two patterns of participation were evident from narrative descriptions of postcamp riding: "riders" and "not there yet." Major facilitating factors were the camp itself, the interaction between the camp and the health service, and continued parent involvement. The program transferred well to home for children who were riding independently on the last day of camp. Ongoing support is needed for children "not there yet."

The primary motor cortex (M1) supports motor skill learning, yet little is known about the genes that contribute to motor cortical plasticity. Such knowledge could identify candidate molecules whose targeting might enable a new understanding of motor cortical functions, and provide new drug targets for the treatment of diseases which impair motor function, such as ischemic stroke. Here, we assess changes in the motor-cortical transcriptome across different stages of motor skill acquisition. Adult rats were trained on a gradually acquired appetitive reach and grasp task that required different strategies for successful pellet retrieval, or a sham version of the task in which the rats received pellet reward without needing to develop the reach and grasp skill. Tissue was harvested from the forelimb motor-cortical area either before training commenced, prior to the initial rise in task performance, or at peak performance. Differential classes of gene expression were observed at the time point immediately preceding motor task improvement. Functional clustering revealed that gene expression changes were related to the synapse, development, intracellular signaling, and the fibroblast growth factor (FGF) family, with many modulated genes known to regulate synaptic plasticity, synaptogenesis, and cytoskeletal dynamics. The modulated expression of synaptic genes likely reflects ongoing network reorganization from commencement of training till the point of task improvement, suggesting that motor performance improves only after sufficient modifications in the cortical circuitry have accumulated. The regulated FGF-related genes may together contribute to M1 remodeling through their roles in synaptic growth and maturation.

Purpose: To evaluate and compare the performance of several designs of 20-gauge dual port (DP) vitreous cutter tips with a standard 20-gauge single port tip., Methods: Custom 20-gauge pneumatic vitreous DP cutter tips with different sizes and port positions were evaluated through porcine vitreous and water flow rates. Five designed and fabricated DP cutter tips were compared with a normal single port control tip and evaluated by the measurement of water and porcine vitreous flow rates, and surgical examination in enucleated porcine eyes., Results: Some DP tips approached a maximum vitreous and water flow rates, removing water and vitreous faster than the normal control tip. With reference to surgical evaluation, some DP tips performed better than the single port tip for bulk vitrectomy, but none shaved the vitreous base more effectively., Conclusion: The DP cutter system has the potential to increase the flow rates depending on the size and position of the extra port. In the future, the DP cutter may allow the surgeon to perform bulk vitrectomy more efficiently.

Purpose: To evaluate the duty cycle of different vitrectomy cutters and classify their blade movement., Methods: A precise weighing (0.01 g) high speed (2 samples/s) balance was used to study the 20-gauge and 25-gauge Bausch & Lomb Lightning-Millenium (St. Louis, MO), the 20-gauge (1500 cpm) and the 25-gauge Alcon Accurus (Fort Worth, TX), the 20-gauge Alcon Innovit, and the 23-gauge DORC (Netherlands) cutters. The weight of balanced saline solution (BSS) was recorded in real time using LabView software and then translated into a graph of volume removed versus time. Variable cut rates and vacuum pressures were analyzed in vitreous and BSS. A high-speed (400 frames/s) camera was used to record cutting for each condition., Results: Three types of duty cycle were investigated: parabolic incomplete (pneumatic), sinusoid (electric), and trapezoid (double pneumatic). The parabolic incomplete and trapezoid had a decreased duty cycle at 1500 cuts per minute when it was compared to 600 cuts per minute. The sinusoid had no statistical difference between cut rates., Conclusions: Systems showed different performances of duty cycle. This new classification will be useful for improved understanding of vitrectomy in these different systems.

Purpose: To determine the influence of port geometry on water and vitreous flow rates and test novel vitreous cutter tips in specific surgical situations., Methods: Custom 20-gauge and 25-gauge vitreous cutter tips with different sized ports were evaluated through porcine vitreous and water flow rates. Five cutter tips were designed and fabricated for specific surgical functionalities. Tips were compared with a normal control tip and evaluated by water and porcine vitreous flow rates, vacuum level required to cut porcine retina, time required to cut and aspirate a porcine lens, and surgical evaluation in enucleated porcine eyes., Results: Both vitreous and water flow asymptotically approached a maximum flow as the port diameter increased. Some tips removed water faster than the normal control tip, but none removed vitreous or lens faster. Several tips required higher vacuum levels to cut retina than the normal tip., Conclusions: Increasing the port diameter of a vitreous cutter to increase flow becomes less effective as the port becomes larger. Furthermore, modifying the port geometry of a vitreous cutter affects its surgical interactions with tissue. In the future, combinational instruments or surgery specific instruments may allow the surgeon to use an optimal port for a specific surgical task.

Purpose: To evaluate porcine vitreous flow and balanced saline solution (BSS) flow rates in different vitrectomy systems., Methods: Porcine vitreous was obtained within 24 hours of slaughter. A high-speed (2 samples/s) balance, precise to 0.01 g, was used. Variable cut rates and vacuum pressures were analyzed in vitreous and BSS. The vitreous was labeled with glass microspheres and triamcinolone acetonide. A high-speed (400 frames/s) camera was used to record cutting for each condition., Results: For all cutters, there was no vitreous flow at zero cut rates (off). In 25-gauge cutters, at 500 mmHg of vacuum, the electric cutter produced higher average flow rates at high cut rates (600 cpm, 0.004 mL/s, and 1500 cpm, 0.013 mL/s) than pneumatic, which demonstrated a decreased flow at speeds higher than 1000 cpm (1000 cpm, 0.015 mL/s, and 1500 cpm, 0.006 mL/s). The percentage of vitreous flow rate/BSS flow rate in different aspiration and cut rates showed an ascending curve. This demonstrates evidence of flow obstruction in 25- (all cut rates), 23- (all cut rates), and 20-gauge (all cut rates). Flow obstruction and surge movements were seen in the high-speed videos., Conclusions: The vitrectomy systems each illustrate different performances of vitreous removal. The physical characteristics of vitreous resulted in nonuniform flow in all vitreous cutters.

Ultrasonic parameters of sound velocity and frequency-dependent attenuation ranging from 25 to 45 MHz were measured for the purpose of evaluating the hardness of lenses in cataract surgery (phacoemulsification). Measurements were performed with a 35-MHz ultrasonic transducer on porcine lenses in which artificially cataracts were induced. The hardness of the cataractous lens was also evaluated by mechanical measurement of its elastic properties. The results indicated that the ultrasonic attenuation coefficients in normal porcine lenses were approximately 4.49 +/- 0.05 (mean +/- SD) and 6.32 +/- 0.04 dB/mm at 30 and 40 MHz, respectively. The development progression of the cataracts resulted in the attenuation coefficient increasing linearly to 7.36 +/- 0.25 and 11.1 +/- 0.92 dB/mm, respectively, corresponding to an increase of Young's modulus from 2.6 to 101.2 kPa. The sound velocity concomitantly increased from 1639.8 +/- 4.2 to 1735.6 +/- 10.4 m/s. Evaluation of the relationship between the phacoemulsification energy level and ultrasonic parameters in vitro by surgeons revealed that both the attenuation coefficient and sound velocity were linearly correlated with the phacoemulsification energy (r = 0.941 and 0.915, respectively). These results showed that measuring high-frequency ultrasonic parameters provides surgeons with good capability and reproducibility for selecting the optimal energy level for phacoemulsification.

Purpose: To design an improved self-stabilizing lens ring for 25-gauge vitrectomy., Design: Device report., Methods: A lens ring was designed to be fixated to the globe using 25-gauge transconjunctival cannulas., Results: This ring consists of a single plastic component with multiple concavities at the ring margin to fit 25-gauge cannulas. The ring can accommodate conventional standard and panoramic vitrectomy lenses., Conclusions: A lens ring has been designed for 25-gauge vitrectomy and to hold conventional contact lenses. Stability of the lens ring is achieved without the need for sutures and instead is achieved by the three point fixation provided by the existing 25-gauge cannula system.

Chronic pneumonia developed in 14 pigs inoculated with an attenuated strain of African swine fever (ASF) virus. The pathogenesis of the pneumonia was as follows: (1) Interalveolar septums became thickened by accumulation of lymphocytes and monocytes; (2) lung developed focal areas of lymphocytes and macrophages; (3) necrosis began abruptly in these foci, beginning with the cells in the alveolar lumens, developing in centrifugal direction, and eventually affecting all structures in its path; (4) necrotic tissue became calcified; and (5) a mantle of mononuclear cells (including plasma cells) and fibrous tissue formed around the necrotic area. Viremia occurred in the 14 pigs at postinoculation day (PID) 14, and precipitating antibody was increased significantly at PID 58.

This article presents an analysis of the community health activities of Chogoria Hospital, Kenya, as they evolved from a typical 'outreach' programme to a heavily community-based one, and the factors that contributed to this conversion. Factors considered include family planning, being the central theme of the programme since its inception, financing, and the impact of the programme is illustrated with data from an extensive evaluation carried out in 1985. The question of long-term financial viability is addressed, contrasting the desired self-sufficiency with the need and extent of donor contributions and finally a number of key factors are listed that may have been important to the success of the programme.