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Karen L Christopher,1 Jennifer L Patnaik,1 Cristos Ifantides,1 D Claire Miller,1 Richard S Davidson,1 Michael J Taravella,1 Anne Lynch,1 Brandie Wagner2 1University of Colorado Anschutz Medical Campus, Department of Ophthalmology, Aurora, CO, USA; 2Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, USACorrespondence: Karen L Christopher 1675 Aurora Ct MS 731, Aurora, CO, 80045, USATel +1 720-848-2508Fax +1 720-848-5014Email karen.christopher@cuanschutz.eduPurpose: To evaluate the time cost of intraoperative aberrometry (IA), to compare IA prediction error to the prediction error associated with conventional formulas using preoperative calculations (PC) and evaluate when IA provides clinically relevant benefit.Methods: This is a retrospective study of eyes that underwent cataract phacoemulsification surgery with IA at an academic eye center. IA versus PC prediction error were compared amongst various preoperative and intraoperative characteristics. Additionally, a dichotomous variable indicating clinically relevant benefit of IA, where IA absolute prediction error was less than 0.5D and PC absolute prediction error greater than 0.5D, was associated with clinical factors.Results: Five hundred eyes of 341 patients were included in the analysis. The quantitative difference between mean absolute prediction errors for IA versus PC was between 0.0D and 0.03D in most subgroups. For the 11.0% of eyes that had clinically relevant benefit to IA, the multivariable model identified the following strongest predictors: prior myopic corneal refractive surgery (Odds ratio (OR) 3.9, p< 0.01 for myopic LASIK/PRK, OR 5.5, p=0.01 for radial keratotomy), toric or multifocal/EDOF lens implantation (OR 2.7, p=0.03 for toric monofocal lenses, OR 3.1, p=0.01 for EDOF/multifocal lenses), and short and long axial lengths (p< 0.01). On average, IA implementation added 3.0 minutes to surgery (p< 0.01).Conclusion: For greatest likelihood of a clinically meaningful improvement in outcomes despite increased surgical time, surgeons and patients should consider using IA for eyes with extremes in axial length, eyes with prior myopic corneal refractive surgery, or when implanting lenses with toric or extended-depth-of-focus/multifocal properties.Keywords: intraoperative aberrometry, IOL calculations, cataract refractive outcomes

Introduction: The standard treatment of femoral shaft fractures in young children (immediate spica casting) and in skeletally mature adolescents (rigid antegrade IM nailing) is widely accepted. For children between these ages (~6-16 y/o), traction and spica casting has traditionally been used. There is growing enthusiasm for Titanium Elastic Nails (TEN) for this age group, but no prospective outcome studies have compared TEN to standard traction and casting. We designed a prospective outcome study to compare the clinical, radiographic, functional, emotional, social and financial consequences of femur fracture management in children 6-16 y/o. Methods: After IRB approval, every child 6-16 y/o who presented to our institution with a femoral shaft fracture was enrolled. Surgeon preference determined treatment method, and some surgeons would not use TEN for any fracture. Each family was asked to complete the AAOS Pediatric Outcome Instrument (Baseline and 6 wks., 3 mo., 6 mo., and 1 year Follow Up). In addition to clinical and radiographic information, we documented important recovery milestones (e.g. time absent from school). Complications (unacceptable alignment or leg length inequality, refracture, unplanned re-operation, decubitus ulcers, etc) were recorded. Results: To date, 21 fractures (in 21 children, mean age 8.5 y/o) treated with traction and casting (T&C) and 28 fractures (27 children, mean age 9.9 y/o) treated with TEN have been followed to the clinical endpoint of fracture union and return to full activity. Compared to T&C, children treated with TEN were discharged sooner (4 vs. 19 days), walked sooner (16 vs. 65 days), walked independently sooner (60 vs. 105 days), and returned to school sooner (55 vs. 99 days). Complication, as defined above, occurred in 11/21 (52%) T/C group patients and in 3/28 (9%) fractures treated with TEN. Conclusion: Children 6-16 y/o who had their femoral shaft fracture treated with Titanium Elastic Nailing were mobilized more quickly, returned to school and other normal activities more quickly, and had a lower complication rate than those treated with traction and casting., JM Flynn, MD, J Dawson, RN, J D'Italia, RN, DS Drummond, MD, RS Davidson, MD, TJ Ganley, MD, B Teti, RN, JP Dormans, MD, JR Gregg, MD, ML Ecker, MD [...]

Unlabelled: Circular fixators have been used successfully to correct multiplanar deformities but are often cumbersome and may be difficult to apply. We determined whether a monolateral fixator, which allows for correction of angular deformity and displacement in three planes, can correct lower extremity deformities to within normal radiographic means (anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, and tibial femoral angle). We retrospectively reviewed the clinical records and radiographs of 22 consecutive patients (25 limbs) who underwent deformity correction using a new multiaxial monolateral external fixator. The patients were 4 to 16 years of age. We had a minimum 1.2-year followup (mean, 2.14 years; range, 1.2-3.1 years). Those with primary femoral and tibial deformities had improvements in the mean deviation from normal of the anatomic lateral distal femoral angle, anatomic medial proximal tibial angle and tibial femoral angle. Patients with Blount's disease had improvements in the mean anatomic medial proximal tibial angle from 59.9 masculine to 87.8 masculine. Five patients had complications (two pin site infections, one premature consolidation, one knee flexion contracture, one recurrence of varus). Six patients developed secondary deformities, all of which were corrected using the primary or secondary hinge. We conclude this fixator can produce satisfactory results with relatively few complications.Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Congenital anterolateral bowing of the tibia is a pre-pseudarthrosis stage of congenital pseudarthrosis of the tibia and is associated with a substantial risk of fracture and pseudarthrosis. We evaluated the results of prophylactic bypass grafting performed in combination with bracing to prevent fracture and pseudarthrosis.Methods: This retrospective series included ten patients with pre-pseudarthrosis of the tibia treated, between 1991 and 2002, with prophylactic bypass grafting with an allograft fibula placed posteromedially in a stress-bearing fashion. The average patient age was 2.3 years at the time of diagnosis, 3.6 years at the time of surgery, and ten years at the time of final follow-up. The mean duration of follow-up was seventy-eight months. Brace protection was recommended at the time of diagnosis and was continued after the operation until maturity. Despite the bracing, a low-energy fracture developed and partially healed prior to the bypass grafting in one patient. The remaining nine patients had no fractures prior to the bypass grafting. At the time of final follow-up, the patients were examined clinically and radiographically for the presence of a fracture or pseudarthrosis and for residual deformity, including malalignment, ankle and knee joint abnormalities, and leg length discrepancy.Results: No patient had either a fracture or a pseudarthrosis of the tibia at the time of follow-up. All grafts united to the tibia at both ends. Complications included an allograft fracture in three patients, which healed in all; allograft resorption in one patient; and pseudarthrosis of the ipsilateral host fibula in one patient. At the time of final follow-up, a mean of 9 mm (range, 0 to 37 mm) of leg length discrepancy was found. A corrective osteotomy was done for four patients (three because of ankle valgus and one because of diaphyseal deformity).Conclusions: In this small series of ten patients with congenital anterolateral bowing of the tibia treated with bypass strut grafting and long-term bracing, there were no cases of pseudarthrosis of the tibia. Distal tibial deformity may persist throughout the growth period and require operative correction in patients treated with this procedure.Level Of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Unlabelled: The purpose of this study was to define the acetabular changes associated with coxa vara and determine how these acetabuli differ from those of a normal hip. Charts and radiographs of 33 patients with coxa vara with a mean age of 6 years (range, 2-15 years) were retrospectively reviewed. The diagnosis was developmental coxa vara in 21 patients and congenital femoral deficiency in 12. Radiographic measurements, including acetabular index, sourcil slope, center edge angle, migration index, and medial joint space, were compared with those of 29 hips in the control group. The inclination of the acetabulum or acetabular slope (as measured by the acetabular index and sourcil slope) was significantly increased in the hips with coxa vara as compared with those in the control group. Both parameters have a statistically significant inverse correlation with the degree of varus, ie, the greater the varus of the proximal femur, the greater the upsloping of the acetabulum. Joint subluxation, as measured by the center edge angle, migration index, and medial joint space, showed little difference from that of control subjects.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Osteochondromas are the most common benign bone tumor; nonetheless, the natural history is poorly understood as a result of the low threshold for resection and the fact that many of these lesions are asymptomatic and therefore never diagnosed. We report a case of spontaneous regression of a solitary osteochondroma and review the literature. We believe the likelihood of spontaneous regression should be better understood by orthopaedic surgeons and taken into account in the decision process of whether to remove osteochondromas surgically. [ABSTRACT FROM AUTHOR]

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared., (Copyright © 2024. Published by Elsevier Inc.)

Aim: To investigate sex-based differences in the occurrence of intra-operative and post-operative complications and associated visual outcomes following cataract surgery., Methods: This was a retrospective study of patients who had phacoemulsification cataract surgery at the University of Colorado School of Medicine. Data collected included the patient's health history, ocular comorbidities, operative and post-operative complications, and the post-operative best corrected visual acuity (BCVA). The data were analyzed using univariate and multivariable logistic regression with generalized estimating equations to account for the correlation of some patients having two eyes included in the study., Results: A total of 11 977 eyes from 7253 patients were included in the study. Ocular comorbidities differed by sex, with males having significantly higher percentages of traumatic cataracts (males 0.7% vs females 0.1%), prior ocular surgery (6.7% vs 5.5%), and mature cataracts (2.8% vs 1.9%). Conversely, females had significantly higher rates of pseudoexfoliation (2.0% vs 3.2%). In unadjusted analysis, males had higher rates of posterior capsular rupture (0.8% vs 0.4%) and vitreous loss (1.0% vs 0.6%), but this difference was not significant after adjustment for confounders. Males had a significantly increased risk of post-operative retinal detachment, but in multivariable analysis this was no longer significant. Males were significantly less likely to undergo post-operative neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy for posterior capsule opacification (OR=0.8, 95%CI=0.7-0.9, P =0.0005). The BCVA was slightly worse for males pre-operatively; but post-operatively, both sexes exhibited similar visual acuity of Snellen equivalent 20/25., Conclusion: The study finds that in a cohort of patients presenting for cataract surgery, sex differences exist in pre-operative comorbidities and surgical characteristics that contribute to higher rates of some complications for males. However, observed surgical complication rates exhibit almost no difference by sex after adjusting for pre-operative differences and post-operative BCVA is similar between sexes., (International Journal of Ophthalmology Press.)

Purpose: The aim of this study was to compare endothelial cell loss for DMEK (Descemet membrane endothelial keratoplasty) tissue preparation techniques using the modified Jones tube and the DMEK EndoGlide with and without viscoelastic material to protect the endothelium., Methods: This ex vivo study included 10 DMEK grafts prepared using each of the 3 abovementioned techniques. After tissue preparation, transport conditions were simulated for a minimum of 45 hours before deployment of the DMEK tissue and quantification of endothelial cell loss. Comparisons between preparation technique groups were made using the Wilcoxon rank-sum test., Results: The Jones tube group had a mean endothelial cell loss of 11.0 ± 4.8% compared with the EndoGlide group with 12.9 ± 6.7% and the EndoGlide with viscoelastic group with 25.7 ± 15.0%. The differences between the EndoGlide with viscoelastic group and the other 2 were statistically significant both before (P < 0.01 and P = 0.01) and after (P = 0.01 and P = 0.02) adjusting for baseline characteristics. The difference between the EndoGlide and Jones tube groups was not significant (P = 0.73 and P = 0.53 after adjustment). Microscopy revealed endothelial cell loss in the area of viscoelastic use for the EndoGlide with viscoelastic group., Conclusions: Both the Jones tube and DMEK EndoGlide resulted in similar low rates of endothelial cell loss after tissue preparation, transport, and deployment. However, use of viscoelastic material to protect the endothelium using the DMEK technique actually resulted in increased cell loss in the area of its application resulting in overall higher rates of cell loss across the DMEK tissue., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The implementation of OpenNotes and corresponding increase in patient access to medical records requires thorough assessment of the risks and benefits of note-sharing. Ophthalmology notes are unique among medical records in that they extensively utilize non-standardized abbreviations and drawings; they are often indecipherable even to highly-educated clinicians outside of ophthalmology. No studies to date have assessed ophthalmologist perceptions of OpenNotes., Methods: A cross-sectional study was conducted from 4/28 to 5/12/2016. A survey was distributed to 30 clinicians (25 ophthalmologists, three optometrists, two nurses) in the University of Colorado's Department of Ophthalmology to evaluate provider attitudes towards granting patients access to online medical records., Results: Many clinicians felt patients would have difficulty understanding their records and may be unnecessarily alarmed or offended by them. Some clinicians worried their workload would increase and feared having to change the way they document. Perceived benefits of OpenNotes included improving patient understanding of their medical conditions, strengthening patient-physician trust, and enhancing patient care. Many perceived risks and benefits of note-sharing were associated with conceptions of the ideal clinician-patient relationship., Conclusions: Clinicians in ophthalmology perceived both benefits and consequences of increasing patient access to ophthalmic records, and there were significant correlations between these perceptions and their conceptions of the clinician-patient relationship. This is the first study to assess potential ophthalmology provider attitudes toward sharing ophthalmic records. Although limited in sample size and power, this study demonstrates some ways patient-accessible ophthalmic records can affect the clinical practice of ophthalmology and emphasizes the unique challenges of OpenNotes in ophthalmology., (© 2021. The Author(s).)

Objective: National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma (CM) recommend physicians consider increased surveillance for patients who typically have lower melanoma survival rates (stages IIB-IV as determined by the American Joint Committee on Cancer (AJCC), 8th edition). However, up to 15% of patients identified as having a low recurrence risk (stages I-IIA) experience disease recurrence, and some patients identified as having a high recurrence risk will not experience any recurrence. The 31-gene expression profile test (31-GEP) stratifies patient recurrence risk into low (Class 1) and high (Class 2) and has demonstrated risk-appropriate impact on disease management and clinical decisions., Methods: Five-year plans for lab work, frequency of clinical visits, and imaging pre- and post-31-GEP test results were assessed for a cohort of 509 stage I-III patients following an interim subset analysis of 247 patients., Results: After receiving 31-GEP results, 50.6% of patients had a change in management plans in at least one of the following categories-clinical visits, lab work, or surveillance imaging. The changes aligned with the risk predicted by the 31-GEP for 76.1% of patients with a Class 1 result and 78.7% of patients with a Class 2 result. A Class 1 31-GEP result was associated with changes toward low-intensity management recommendations, while a Class 2 result was associated with changes toward high-intensity management recommendations., Conclusion: The 31-GEP can stratify patient recurrence risk in patients with CM, and clinicians understand and apply the prognostic ability of the 31-GEP test to alter patient management in risk-appropriate directions.

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Purpose: To determine the prevalence of physician burnout among ophthalmologists in the United States and identify associated risks., Setting: All practice types within the United States., Design: Cross-sectional study., Methods: A survey was distributed through email listservs to several national ophthalmology societies. Participants completed a modified Mini Z Burnout Survey, a 10-item questionnaire measured in 5-point Likert scales, followed by demographic questions. The Mini Z Burnout survey assessed 3 main outcomes: stress, burnout, and work satisfaction. The percentage of subgroups experiencing burnout were presented and comparisons made with odds ratios from logistic regression modeling., Results: Of the 592 ophthalmologists responding to the survey, 37.8% (224) self-reported symptoms of burnout with a low of 30.8% (12/39) for vitreoretinal specialists to a high of 45.4% (30/66) for uveitis specialists. Most of those reporting burnout were categorized as mild (65.2% [146/224]), followed by moderate (29.5% [66/224]) and severe (5.4% [12/224]). Women had almost twice the odds of reporting burnout (odds ratio [OR] = 1.9 [95% CI: 1.3-2.7]; P = .0005). Physicians employed in academic (OR = 2.0 [95% CI: 1.2-3.2]; P = 0.007) and hospital facilities (OR = 2.4 [95% CI: 1.3-4.6]; P = .008) reported higher rates of burnout compared with those in large private groups. Burnout was associated with self-reported low work control, insufficient time for documentation, and misalignment with departmental leaders (P < .0001)., Conclusions: Ophthalmologists exhibited a high degree of self-reported burnout in the U.S. This study highlights sex, employment autonomy, and practice type as major factors associated with burnout., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Trade is a complex, multi-faceted process that can contribute to the spread and persistence of disease. We here develop novel mechanistic models of supply. Our model is framed within a livestock trading system, where farms form and end trade partnerships with rates dependent on current demand, with these trade partnerships facilitating trade between partners. With these time-varying, stock dependent partnership and trade dynamics, our trading model goes beyond current state of the art modelling approaches. By studying instantaneous shocks to farm-level supply and demand we show that behavioural responses of farms lead to trading systems that are highly resistant to shocks with only temporary disturbances to trade observed. Individual adaptation in response to permanent alterations to trading propensities, such that animal flows are maintained, illustrates the ability for farms to find new avenues of trade, minimising disruptions imposed by such alterations to trade that common modelling approaches cannot adequately capture. In the context of endemic disease control, we show that these adaptations hinder the potential beneficial reductions in prevalence such changes to trading propensities have previously been shown to confer. Assessing the impact of a common disease control measure, post-movement batch testing, highlights the ability for our model to measure the stress on multiple components of trade imposed by such control measures and also highlights the temporary and, in some cases, the permanent disturbances to trade that post-movement testing has on the trading system., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background Pediatric patients often present with vague complaints involving the anterolateral foot and ankle, the medial knee, the lower back, and the hip. In our experience, closer examination of these patients reveals a constellation of symptoms that involve pathology in the ankle, knee, back, and hip. This study aimed to detail the identification and treatment of patients with the triad of flexible flat feet, tight Achilles complex, and altered gait, and their clinical course over time. Methods All patients of age 18 years or younger who presented to our urban academic center outpatient clinic with foot, ankle, patellar, low back, or hip pain or pathology were included. Patients with identified tarsal coalitions, accessory naviculars, malalignment syndrome, bone cysts or tumors, soft tissue tumors, arthropathy, neuropathy, infection, limb length inequality, patellar subluxation or dislocation, or spinal pathology were excluded. For each patient, demographic information, symptom description, treatment, and clinical course, including the Foot and Ankle Outcome Score (FAOS) was recorded. Results A total of 62 patients were included in our study. Patients mostly presented with low back pain (n=24, 38.7%), medial patellar pain (n=36, 58.1%), anterolateral ankle pain (n=35, 56.5%), and vague foot pain (n=13, 21.0%). Overall, 53.8% of patients with back pain at the initial visit, 35.0% of patients with knee pain, 44.4% of patients with ankle pain and 80.0% of patients with foot pain improved at final follow up. While patient-reported sports and recreation subscale scores demonstrated a significant improvement at the final follow-up compared to baseline scores (p=0.02), all other scores did not significantly differ compared to baseline scores. At final follow-up, 12 of 26 (46.2%) patients reported being able to return to play in their desired sport. Conclusion Complaints of back, hip, knee, ankle, or foot pain in the pediatric population can be early markers for a constellation of conditions that include low back pain, flexible flat feet, Achilles contracture, and altered gait due to increased lateral subluxation of the patella and hip flexion., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Malige et al.)

Variants of the susceptible-infected-removed (SIR) model of Kermack & McKendrick (1927) enjoy wide application in epidemiology, offering simple yet powerful inferential and predictive tools in the study of diverse infectious diseases across human, animal and plant populations. Direct transmission models (DTM) are a subset of these that treat the processes of disease transmission as comprising a series of discrete instantaneous events. Infections transmitted indirectly by persistent environmental pathogens, however, are examples where a DTM description might fail and are perhaps better described by models that comprise explicit environmental transmission routes, so-called environmental transmission models (ETM). In this paper we discuss the stochastic susceptible-exposed-infected-removed (SEIR) DTM and susceptible-exposed-infected-removed-pathogen (SEIR-P) ETM and we show that the former is the timescale separation limit of the latter, with ETM host-disease dynamics increasingly resembling those of a DTM when the pathogen's characteristic timescale is shortened, relative to that of the host population. Using graphical posterior predictive checks (GPPC), we investigate the validity of the SEIR model when fitted to simulated SEIR-P host infection and removal times. Such analyses demonstrate how, in many cases, the SEIR model is robust to departure from direct transmission. Finally, we present a case study of white spot disease (WSD) in penaeid shrimp with rates of environmental transmission and pathogen decay (SEIR-P model parameters) estimated using published results of experiments. Using SEIR and SEIR-P simulations of a hypothetical WSD outbreak management scenario, we demonstrate how relative shortening of the pathogen timescale comes about in practice. With atttempts to remove diseased shrimp from the population every 24h, we see SEIR and SEIR-P model outputs closely conincide. However, when removals are 6-hourly, the two models' mean outputs diverge, with distinct predictions of outbreak size and duration., Competing Interests: The authors have declared that no competing interests exist.

National guidelines recommend sentinel lymph node biopsy (SLNB) be offered to patients with > 10% likelihood of sentinel lymph node (SLN) positivity. On the other hand, guidelines do not recommend SLNB for patients with T1a tumors without high-risk features who have < 5% likelihood of a positive SLN. However, the decision to perform SLNB is less certain for patients with higher-risk T1 melanomas in which a positive node is expected 5%-10% of the time. We hypothesized that integrating clinicopathologic features with the 31-gene expression profile (31-GEP) score using advanced artificial intelligence techniques would provide more precise SLN risk prediction., Methods: An integrated 31-GEP (i31-GEP) neural network algorithm incorporating clinicopathologic features with the continuous 31-GEP score was developed using a previously reported patient cohort (n = 1,398) and validated using an independent cohort (n = 1,674)., Results: Compared with other covariates in the i31-GEP, the continuous 31-GEP score had the largest likelihood ratio (G 2 = 91.3, P < .001) for predicting SLN positivity. The i31-GEP demonstrated high concordance between predicted and observed SLN positivity rates (linear regression slope = 0.999). The i31-GEP increased the percentage of patients with T1-T4 tumors predicted to have < 5% SLN-positive likelihood from 8.5% to 27.7% with a negative predictive value of 98%. Importantly, for patients with T1 tumors originally classified with a likelihood of SLN positivity of 5%-10%, the i31-GEP reclassified 63% of cases as having < 5% or > 10% likelihood of positive SLN, for a more precise, personalized, and clinically actionable SLN-positive likelihood estimate., Conclusion: These data suggest the i31-GEP could reduce the number of SLNBs performed by identifying patients with likelihood under the 5% threshold for performance of SLNB and improve the yield of positive SLNBs by identifying patients more likely to have a positive SLNB., Competing Interests: John T. Vetto Employment: Gilead Sciences (I) Stock and Other Ownership Interests: Gilead Sciences (I), Roche/Genentech (I) Speakers' Bureau: Castle Biosciences Travel, Accommodations, Expenses: Castle Biosciences No other potential conflicts of interest were reported. John T. Vetto Employment: Gilead Sciences (I) Stock and Other Ownership Interests: Gilead Sciences (I), Roche/Genentech (I) Speakers' Bureau: Castle Biosciences Travel, Accommodations, Expenses: Castle Biosciences No other potential conflicts of interest were reported., (© 2021 by American Society of Clinical Oncology.)

Background Supracondylar humerus fractures (SCH) are common upper extremity fractures in children and are usually treated by closed reduction and percutaneous pinning. Post-operative management may cause complications, but the difference between cast and splint has not been closely investigated. Purpose Our objective was to compare casting and splinting of SCH fractures with respect to post-operative complications. Patients and methods We reviewed 1,146 pediatric SCH fractures that were reduced, percutaneously pinned, and immobilized by cast or splint. Open fractures, openly reduced fractures, and pre-operative neurological injuries were excluded. Over the course of immobilization, we noted if the initial cast or splint was maintained and if the patient returned due to complications. Results Post-operative casting was performed on 1,091 (95.2%) fractures and 55 (4.8%) were splinted. Age was a significant factor, increasing the likelihood of splinting by 12% with each year of age (p = 0.023). A total of 28 patients (2.4%) returned for unscheduled visits due to immobilization complaints, infection, and pain, but the rate difference between cast and splint was negligible. Reoperation was required for five patients (0.4%), and more likely for splinted fractures (p = 0.021). After controlling for age, splinting was still associated with reoperation (OR: 15.1, p = 0.004). Conclusions Although complications inevitably exist, both casting and splinting are effective immobilization methods. Both resulted in few complications such as post-operative discomfort, pain, infection, loss of reduction, or damage. It was difficult to evaluate significance with few splinted cases, but considering no major differences between splinted and casted fractures, clinicians should consider splinting to reduce the cost associated with casting., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2021, Lee et al.)

Aim: To quantify intraoperative and postoperative complications in complex phacoemulsification cataract extraction (phacoemulsification) with iris manipulation compared to non-complex and complex phacoemulsification without iris manipulation., Methods: All phacoemulsification cases at the University of Colorado between January 1, 2014, and June 30, 2017 were included. Exclusion criteria for the primary outcome of intraoperative complications were planned combination surgery and eyes with less than 28d follow-up. Exclusion criteria for the secondary outcomes of postoperative complications were unplanned additional surgery, and chronic steroid eye drop use prior to surgery. Data including sex, race/ethnicity, surgery length, visual acuity, intraoperative and postoperative complications, and intraocular pressures (IOP) were collected and analyzed utilizing general linear and Logistic regression modeling., Results: The medical records of 5772 eyes were reviewed (500 complex without iris manipulation, 367 with iris manipulation). The number of any intraoperative complication in the complex with iris manipulation and complex without iris manipulation groups was 15 (4.1%) and 26 (5.2%), respectively, compared to 41 (0.8%) in the non-complex group. Postoperative inflammation was found in 135 (2.8%) non-complex cases, 20 (4.1%) complex cases without iris manipulation, and 20 (5.6%) complex cases with iris manipulation. The adjusted odds ratio of postoperative inflammation in phacoemulsification with iris manipulation compared to non-complex was 2.3 (95%CI: 1.3-4.0, P =0.005). The rate of IOP spikes >10 mm Hg was significantly greater in cases with iris manipulation ( P =0.001)., Conclusion: Complex cases have more intraoperative complications. However, only complex cases with iris manipulation led to increase rates of postoperative inflammation and IOP spikes >10 mm Hg., (International Journal of Ophthalmology Press.)

Case: A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques., Conclusions: In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B384)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

We develop and apply analytically tractable generative models of livestock movements at national scale. These go beyond current models through mechanistic modelling of heterogeneous trade partnership network dynamics and the trade events that occur on them. Linking resulting animal movements to disease transmission between farms yields analytical expressions for the basic reproduction number R 0 . We show how these novel modelling tools enable systems approaches to disease control, using R 0 to explore impacts of changes in trading practices on between-farm prevalence levels. Using the Scottish cattle trade network as a case study, we show our approach captures critical complexities of real-world trade networks at the national scale for a broad range of endemic diseases. Changes in trading patterns that minimize disruption to business by maintaining in-flow of animals for each individual farm reduce R 0 , with the largest reductions for diseases that are most challenging to eradicate. Incentivizing high-risk farms to adopt such changes exploits 'scale-free' properties of the system and is likely to be particularly effective in reducing national livestock disease burden and incursion risk. Encouragingly, gains made by such targeted modification of trade practices scale much more favourably than comparably targeted improvements to more commonly adopted farm-level biosecurity., (© 2021 The Authors.)

Purpose: To assess the accuracy of intraoperative aberrometry, the Barrett True-K No History (Barrett TKNH), Barrett TKNH with posterior corneal measurements (Barrett TKNH with PC), Shammas-PL, and Haigis-L formulas in patients with cataract who had prior myopic refractive surgery., Methods: This was a retrospective consecutive case series of patients with prior myopic refractive surgery undergoing cataract extraction. Mean absolute error (MAE) and median absolute error (MedAE) of refraction prediction were compared for each formula. Interactions of each biometry measurement were modeled for each formula to evaluate those with the most significant impact on refraction prediction., Results: One hundred sixteen eyes of 79 patients were analyzed. MAE was 0.40 ± 0.33 diopters (D) for intraoperative aberrometry and 0.42 ± 0.31 D for the Barrett TKNH, 0.38 ± 0.30 D for the Barrett TKNH with PC, 0.47 ± 0.38 D for the Shammas-PL, and 0.56 ± 0.39 D for the Haigis-L formulas. Comparisons between formulas were significant for Barrett TKNH versus Barrett TKNH with PC formulas (P = .046), Barrett TKNH with PC versus Shammas-PL formulas (P = .023), and for all comparisons with the Haigis-L formula (P < .001), and not significant for all other comparisons (P > .05). Eyes were within ±0.50 D of prediction 73%, 72%, 69%, 62%, and 52% of the time for intraoperative aberrometry, the Barrett TKNH with PC, Barrett TKNH, Shammas-PL, and Haigis-L formulas, respectively. Corneal asphericity (Q value) was significantly associated with prediction error for all five methods. Changes in anterior chamber depth had a significant impact on Shammas-PL prediction errors., Conclusions: Newer technology using information from the posterior cornea modestly improved outcomes when compared to established methods for intraocular lens selection in eyes that had previous laser refractive surgery for myopia. [J Refract Surg. 2021;37(1):60-68.]., (Copyright 2021, SLACK Incorporated.)

Patient satisfaction after modern day cataract surgery requires excellent surgical technique but increasingly demands superior refractive outcomes as well. In many cases, there exists an expectation from patients, as well as surgeons, to achieve emmetropia after cataract surgery. This is particularly true in patients electing premium intraocular lens technology to correct astigmatism and presbyopia to minimize spectacle dependence. Despite continued advances in preoperative and intraoperative diagnostics, refractive planning, and surgical technology, residual refractive error remains a primary source of dissatisfaction after cataract surgery. The need to enhance refractive outcomes and treat residual astigmatic or spherical refractive errors postoperatively becomes paramount to meeting the expectations of patients in their surgical outcome. This article reviews the potential preoperative and intraoperative pitfalls that can be the source of refractive error, the various options to enhance refractive outcomes, and potential future technologies to limit residual refractive error after cataract surgery.

Background and Objective: To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification., Patients and Methods: Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries., Results: Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR., Conclusion: Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.]., (Copyright 2020, SLACK Incorporated.)

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.

Purpose: To compare visual outcomes of eyes with and without previous laser refractive surgery that received an extended depth of focus intraocular lens during cataract surgery., Methods: This was a retrospective review of all eyes implanted with an extended depth of focus intraocular lens by two surgeons. Preoperative demographic and eye examination information were collected, as well as postoperative refraction, uncorrected distance visual acuity, and Visual Function Index (VF-14) questionnaire responses. Medical records were reviewed postoperatively to collect the number of patients who required a refractive touch-up or lens exchange., Results: Most patient eyes (187 of 215, 87%) had no prior refractive surgery, and there was no significant difference in preoperative characteristics between this group and the 28 eyes that did have previous laser refractive surgery. Postoperatively, most patients had a refractive error within ±0.50 diopters (D) (79% without vs 77% with previous laser refractive surgery, P = .40). Although more patients in the group without previous laser refractive surgery achieved 20/20 uncorrected distance visual acuity (UDVA) (56.8% versus 28.6%, P = .01), the majority in both groups achieved 20/25 or better UDVA (79.5% versus 85.7% for without versus with previous laser refractive surgery, P = .42). Postoperative subjective visual function score was also similar between the two groups as measured by the VF-14 questionnaire (86.9 vs 79.4, P = .15). Few patients required refractive surgery enhancement in either group (9 of 187 (4.8%) versus 1 of 28 (3.6%) for without versus with previous laser refractive surgery, P = .77)., Conclusions: The data suggest that extended depth of focus lens implantation can have successful results for patients with prior laser refractive surgery. [J Refract Surg. 2020;36(1):28-33.]., (Copyright 2020, SLACK Incorporated.)

Culling wildlife to control disease can lead to both decreases and increases in disease levels, with apparently conflicting responses observed, even for the same wildlife-disease system. There is therefore a pressing need to understand how culling design and implementation influence culling's potential to achieve disease control. We address this gap in understanding using a spatial metapopulation model representing wildlife living in distinct groups with density-dependent dispersal and framed on the badger-bovine tuberculosis (bTB) system. We show that if population reduction is too low, or too few groups are targeted, a 'perturbation effect' is observed, whereby culling leads to increased movement and disease spread. We also demonstrate the importance of culling across appropriate time scales, with otherwise successful control strategies leading to increased disease if they are not implemented for long enough. These results potentially explain a number of observations of the dynamics of both successful and unsuccessful attempts to control TB in badgers including the Randomized Badger Culling Trial in the UK, and we highlight their policy implications. Additionally, for parametrizations reflecting a broad range of wildlife-disease systems, we characterize 'Goldilocks zones', where, for a restricted combination of culling intensity, coverage and duration, the disease can be reduced without driving hosts to extinction.

The 22q11.2 Deletion Syndrome (22q11.2DS) occurs in ~1:3,000-6,000 individuals. Features less typically associated with 22q11.2DS, such as orthopedic manifestations, may be overlooked or may not lead to appropriate diagnostic testing. Club foot has a general population prevalence of ~1:1,000 and has been occasionally described in association with 22q11.2DS. Our hypothesis is that the prevalence of club foot is higher in patients with 22q11.2DS. We performed a retrospective review in two specialized 22q11.2DS centers to determine the prevalence of club foot. "True club foot" requires treatment (either conservative or surgical), therefore we only included those patients with proof of treatment. We investigated whether congenital heart disease (CHD) and/or cleft palate were associated with the presence of club foot within 22q11.2DS. The records of 1,466 patients were reviewed. Of these, 48 (3.3%) had confirmation of club foot (95% Confidence Interval: 2.4-4.3): 22 (46%) had a bilateral, 12 (25%) left, and 14 (29%) right club foot. Within our study, neither a CHD and/or a cleft palate were associated with a club foot. The prevalence of club foot in 22q11.2DS is 30 times higher than that observed in the general population. This suggests the diagnosis of club foot, especially in the face of other typically associated abnormalities of 22q11.2DS, should provoke consideration of 22q11.2DS as an underlying diagnosis, particularly in the neonatal setting., (© 2018 The Authors. American Journal of Medical Genetics Part A published by Wiley Periodicals, Inc.)

A survey of retail purchased semi-skimmed pasteurised milk (n = 368) for Mycobacterium avium subspecies paratuberculosis (MAP) was conducted between May 2014 and June 2015 across the midlands of England using the Phage-PCR assay. Overall, 10.3% of the total samples collected contained viable MAP cells, confirming that pasteurisation is not capable of fully eliminating human exposure to viable MAP through milk. Comparison of the results gained using the Phage-PCR assay with the results of surveys using either culture or direct PCR suggest that the phage-PCR assay is able to detect lower numbers of cells, resulting in an increase in the number of MAP-positive samples detected. Comparison of viable count and levels of MAP detected in bulk milk samples suggest that MAP is not primarily introduced into the milk by faecal contamination but rather are shed directly into the milk within the udder. In addition results detected an asymmetric distribution of MAP exists in the milk matrix prior to somatic cell lysis, indicating that the bacterial cells in naturally contaminated milk are clustered together and may primarily be located within somatic cells. These latter two results lead to the hypothesis that intracellular MAP within the somatic cells may be protected against heat inactivation during pasteurisation, accounting for the presence of low levels of MAP detected in retail milk., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Respiratory illness causes significant morbidity especially in children, the elderly and the immunocompromised. The sample type taken and the quality of that sample are of great significance in providing an accurate diagnosis. Gargle samples are easy to take and sample the same area as a throat swab (THS). In this study, we assessed the utility of gargle samples for the molecular detection of common respiratory infections. Paired gargle and THS samples collected on the same day from the same patient were compared. We also included in our analysis paired THS and gargle samples that were collected within three days of each other as these samples are likely to have been taken during the same illness. Overall the data suggests that gargle samples are a more sensitive sample type than THS samples as overall the diagnostic yield was higher in the gargle samples and the Ct value of the gargle samples was stronger for the majority of samples in comparison to THS samples. Similar data was seen in the paired samples collected within one to three days of each other, as although the diagnostic yield between the sample types was similar (similar discrepant results), the majority of gargles had stronger Ct values than THS samples. This paper highlights the usefulness of gargle samples as non-invasive sensitive respiratory sample in comparison to THS samples. We recommend that other testing sites should consider using gargle samples for respiratory diagnosis as it will bring benefits in terms of sensitivity and sampling ease of use., (Copyright © 2017. Published by Elsevier B.V.)

The removal and rate of recurrence of pterygium have been discussed for years. The disorder is highly associated with environmental factors, and recurrence rates can be unacceptably high and cannot be successfully predicted. New techniques and graft preparations and postoperative management strategies are helping to reduce the recurrence rates and provide an ocular surface that is near ideal for future cataract or refractive surgery. This review discusses the advantages and disadvantages of various treatment strategies., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the relationship between 1-day postoperative intraocular pressure (IOP) after phacoemulsification cataract surgery and tamsulosin use., Setting: University of Colorado Health Eye Center, Aurora, Colorado, USA., Design: Retrospective cohort study., Methods: Registry data from men who had cataract surgery were used. Patients taking tamsulosin at the time of surgery were included as cases, while patients with no history of tamsulosin use were used as controls. The primary outcome was a 1-day postoperative IOP spike defined as an IOP increase greater than 10 mm Hg compared with baseline or a 1-day postoperative IOP of 30 mm Hg or higher. General estimating equations were used for analysis., Results: The study comprised 584 men (864 eyes). An IOP increase greater than 10 mm Hg or IOP 30 mm Hg or higher after cataract surgery occurred in 12.4% and 9.3%, respectively, of eyes in the tamsulosin group versus 4.4% and 2.1%, respectively, in the control group (all P = .001). After adjusting for significant covariates, patients on tamsulosin were 2.6 times (95% confidence interval [CI], 1.2-5.7; P = .01] and 3.8 (95% CI, 1.3-10.9; P = .01) more likely to have a 1-day postoperative IOP increase greater than 10 mm Hg or a 1-day postoperative IOP of 30 mm Hg or higher., Conclusion: Patients on tamsulosin had an increased risk of a 1-day postoperative IOP spike after cataract surgery, showing the importance of identifying patients on tamsulosin preoperatively to better manage and potentially mitigate IOP spikes., Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objective: DecisionDx-Melanoma * is a 31-gene expression profile test that predicts the risk of metastasis in patients with primary cutaneous melanoma (CM). This study was designed to ascertain clinical management changes determined by the test outcome, which classifies CM patients being at low (Class 1) or high (Class 2) risk for recurrence., Research Design and Methods: Medical charts were reviewed from 156 CM patients from six institutions (three dermatology and three surgical oncology practices) who were consecutively tested between May 2013 and December 2015. Clinical management data that were compiled and compared before and after receipt of the 31-gene expression test result included frequency of physical exams, frequency and modality of imaging, and referrals to surgical and medical oncologists., Results: Forty-two percent of patients were Stage I, 47% were Stage II and 8% were Stage III. Overall, 95 patients (61%) were Class 1 and 61 (39%) were Class 2. Documented changes in management were observed in 82 (53%) patients, with the majority of Class 2 patients (77%) undergoing management changes compared to 37% of Class 1 patients (p < 0.0001 by Fisher's exact test). The majority (77/82, 94%) of these changes were concordant with the risk indicated by the test result (p < 0.0001 by Fisher's exact test), with increased management intensity for Class 2 patients and reduced management intensity for Class 1 patients., Conclusions: Molecular risk classification by gene expression profiling has clinical impact and influences physicians to direct clinical management of CM patients. The vast majority of the changes implemented after the receipt of test results were reflective of the low or high recurrence risk associated with the patient's molecular classification. Because follow-up data was not collected for this patient cohort, the study is limited for the assessment of the impact of gene expression profile based management changes on healthcare resource utilization and patient outcome.

Infectious disease surveillance is key to limiting the consequences from infectious pathogens and maintaining animal and public health. Following the detection of a disease outbreak, a response in proportion to the severity of the outbreak is required. It is thus critical to obtain accurate information concerning the origin of the outbreak and its forward trajectory. However, there is often a lack of situational awareness that may lead to over- or under-reaction. There is a widening range of tests available for detecting pathogens, with typically different temporal characteristics, e.g. in terms of when peak test response occurs relative to time of exposure. We have developed a statistical framework that combines response level data from multiple diagnostic tests and is able to 'hindcast' (infer the historical trend of) an infectious disease epidemic. Assuming diagnostic test data from a cross-sectional sample of individuals infected with a pathogen during an outbreak, we use a Bayesian Markov Chain Monte Carlo (MCMC) approach to estimate time of exposure, and the overall epidemic trend in the population prior to the time of sampling. We evaluate the performance of this statistical framework on simulated data from epidemic trend curves and show that we can recover the parameter values of those trends. We also apply the framework to epidemic trend curves taken from two historical outbreaks: a bluetongue outbreak in cattle, and a whooping cough outbreak in humans. Together, these results show that hindcasting can estimate the time since infection for individuals and provide accurate estimates of epidemic trends, and can be used to distinguish whether an outbreak is increasing or past its peak. We conclude that if temporal characteristics of diagnostics are known, it is possible to recover epidemic trends of both human and animal pathogens from cross-sectional data collected at a single point in time.

Unlabelled: Presbyopia is the most common refractive disorder for people older than 40 years. It is characterized by a gradual and progressive decrease in accommodative amplitude. Many surgical procedures for the correction of presbyopia exist, with additional procedures on the horizon. This review describes the prevalent theories of presbyopia and discusses the available surgical options for correction., Financial Disclosure: Proprietary or commercial disclosures are listed after the references., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Parasitic nematodes represent one of the most pervasive and significant challenges to grazing livestock, and their intensity and distribution are strongly influenced by climate. Parasite levels and species composition have already shifted under climate change, with nematode parasite intensity frequently low in newly colonized areas, but sudden large-scale outbreaks are becoming increasingly common. These outbreaks compromise both food security and animal welfare, yet there is a paucity of predictions on how climate change will influence livestock parasites. This study aims to assess how climate change can affect parasite risk. Using a process-based approach, we determine how changes in temperature-sensitive elements of outbreaks influence parasite dynamics, to explore the potential for climate change to influence livestock helminth infections. We show that changes in temperate-sensitive parameters can result in nonlinear responses in outbreak dynamics, leading to distinct 'tipping-points' in nematode parasite burdens. Through applying two mechanistic models, of varying complexity, our approach demonstrates that these nonlinear responses are robust to the inclusion of a number of realistic processes that are present in livestock systems. Our study demonstrates that small changes in climatic conditions around critical thresholds may result in dramatic changes in parasite burdens.

Purpose: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet., Methods: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up., Results: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet., Conclusion: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.

Resolution, high signal intensity and elevated signal to noise ratio (SNR) are key issues for biologists who aim at studying the localisation of biological structures at the cellular and subcellular levels using confocal microscopy. The resolution required to separate sub-cellular biological structures is often near to the resolving power of the microscope. When optimally used, confocal microscopes may reach resolutions of 180 nm laterally and 500 nm axially, however, axial resolution in depth is often impaired by spherical aberration that may occur due to refractive index mismatches. Spherical aberration results in broadening of the point-spread function (PSF), a decrease in peak signal intensity when imaging in depth and a focal shift that leads to the distortion of the image along the z-axis and thus in a scaling error. In this study, we use the novel mounting medium CFM3 (Citifluor Ltd., UK) with a refractive index of 1.518 to minimize the effects of spherical aberration. This mounting medium is compatible with most common fluorochromes and fluorescent proteins. We compare its performance with established mounting media, harbouring refractive indices below 1.500, by estimating lateral and axial resolution with sub-resolution fluorescent beads. We show furthermore that the use of the high refractive index media renders the tissue transparent and improves considerably the axial resolution and imaging depth in immuno-labelled or fluorescent protein labelled fixed mouse brain tissue. We thus propose to use those novel high refractive index mounting media, whenever optimal axial resolution is required.

Introduction: When used for strict surgical indications, operative management of chronic symptomatic os subfibulare in children involving fragment excision and ligament repair can significantly improve visual analog scale pain scores and result in high Foot and Ankle Outcome Scores., Step 1 Indications and Preoperative Planning: Operative indications are chronic pain at the distal part of the fibula, symptoms of instability at the anterior talofibular ligament and/or calcaneofibular ligament, and a radiographic finding of an os fibulare., Step 2 Ossicle Excision: Perform an approach to the lateral malleolus and excise the fragment while preserving the anterior talofibular ligament and calcaneofibular ligament., Step 3 Ankle Examination: Examine the ankle for loose bodies or other associated damage., Step 4 Preparation for Ligament Repair: Repair the anterior talofibular ligament and calcaneofibular ligament to the debrided distal part of the fibula ., Step 5 Preparation for Modified Broström Procedure: Imbricate the lateral capsule to secondarily reconstruct and reinforce the ligaments, adding to the strength of the repair., Step 6 Repair Reconstruction and Closure: Reduce the ankle joint and tie down the sutures., Step 7 Casting: Patients wear a cast and remain non-weight-bearing for six weeks postoperatively., Step 8 Postoperative Protocol: Patients advance to full weight-bearing in a CAM boot and start physical therapy at six weeks., Results: We performed a retrospective case study of the first twenty-three patients treated with our procedure for symptomatic os subfibulare.IndicationsContraindicationsPitfalls & Challenges.

Population reduction is often used as a control strategy when managing infectious diseases in wildlife populations in order to reduce host density below a critical threshold. However, population reduction can disrupt existing social and demographic structures leading to changes in observed host behaviour that may result in enhanced disease transmission. Such effects have been observed in several disease systems, notably badgers and bovine tuberculosis. Here we characterise the fundamental properties of disease systems for which such effects undermine the disease control benefits of population reduction. By quantifying the size of response to population reduction in terms of enhanced transmission within a generic non-spatial model, the properties of disease systems in which such effects reduce or even reverse the disease control benefits of population reduction are identified. If population reduction is not sufficiently severe, then enhanced transmission can lead to the counter intuitive perturbation effect, whereby disease levels increase or persist where they would otherwise die out. Perturbation effects are largest for systems with low levels of disease, e.g. low levels of endemicity or emerging disease. Analysis of a stochastic spatial meta-population model of demography and disease dynamics leads to qualitatively similar conclusions. Moreover, enhanced transmission itself is found to arise as an emergent property of density dependent dispersal in such systems. This spatial analysis also shows that, below some threshold, population reduction can rapidly increase the area affected by disease, potentially expanding risks to sympatric species. Our results suggest that the impact of population reduction on social and demographic structures is likely to undermine disease control in many systems, and in severe cases leads to the perturbation effect. Social and demographic mechanisms that enhance transmission following population reduction should therefore be routinely considered when designing control programmes.