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Study designCross-sectional analysis of patient educational materials from top pediatric orthopedic hospital websites.ObjectiveTo assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal deformity.Summary of background dataThe internet has become an increasingly popular source of health information for patients and their families. Healthcare experts recommend that the readability of online education materials be at or below a 6th-grade reading level. However, previous studies have demonstrated that the readability of online education materials on various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal deformity has not been analyzed.MethodsOnline patient education materials from the top 25 pediatric orthopedic institutions, as ranked by the U.S. News and World Report hospitals for pediatric orthopedics, were accessed utilizing the following readability assessments: Flesch–Kincaid (FK), Flesch Reading Ease, Gunning Fog Index, Coleman–Liau Index, Simple Measure of the Gobbledygook Index (SMOG), Automated Readability Index, FORCAST, and the New Dale and Chall Readability. Correlations between academic institutional ranking, geographic location, and the use of concomitant multi-media modalities with FK scores were evaluated using a Spearman regression.ResultsOnly 48% (12 of 25) of top pediatric orthopedic hospitals provided online information regarding pediatric spinal deformity at or below a 6th-grade reading level. The mean FK score was 9.0 ± 2.7, Flesch Reading Ease 50.8 ± 15.6, Gunning Fog Score 10.6 ± 3.1, Coleman–Liau Index 11.6 ± 2.6, SMOG index 11.7 ± 2.0, Automated Readability Index 8.6 ± 2.8, and Dale–Chall Readability Score 6.4 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of multimedia with FK scores.ConclusionOnline educational material for pediatric spinal deformity from top pediatric orthopedic institutional websites are associated with poor readability.

OBJECTIVE This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN Retrospective chart and radiographic review. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with cancer in the United States are estimated to have a suicide incidence that is approximately twice that of the general population. Patients with bone and soft tissue cancer often have physical impairments and activity limitations develop that reduce their quality of life, which may put them at high risk for depression, anxiety, and suicidal ideation. To our knowledge, there have been no large studies determining incidence of suicide among patients with bone and soft tissue cancer; this information might allow screening of certain high-risk groups. To determine (1) the incidence of suicide in patients with bone and soft tissue cancer, (2) whether the incidence of suicide is greater in patients with bone and soft tissue cancer than it is in the general US population, and (3) any demographic and tumor characteristics associated with increased suicide incidence. A retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) program was performed. A total of 23,620 patients with primary bone and soft tissue cancer were identified in this database from 1973 and 2013. Patients with a cause of death listed as “suicide and self-inflicted injury” were considered to have committed suicide and suicide incidences were determined for different demographic and tumor characteristics in this subset of patients. Patient data for age, gender, race, marital status, year of diagnosis, primary cancer site, cancer stage, course of treatment, and survival time were collected and analyzed. The incidence of suicide in patients with bone and soft tissue sarcoma was compared with the age-, gender-, and race-adjusted incidence of suicide in the general US population from 1970 to 2013 available from the National Center for Health Statistics through the SEER Program. The overall suicide incidence in this population was 32 per 100,000 person-years, which was higher than the age-, race-, and gender-adjusted US general population suicide incidence of 13 per 100,000 person-years. When compared with the incidence of suicide in matched subgroups of the general US population, a higher suicide incidence was observed in men (standardized mortality ratio [SMR], 2.49; 95% CI, 1.92–3.22; p < 0.001), patients of white race (SMR, 2.68; 95% CI, 1.94–3.56; p < 0.001), patients 21 to 30 years old (SMR, 4.40; 95% CI, 3.44–5.54; p < 0.001) and 61 to 70 years old (SMR, 3.27; 95% CI, 2.54–4.18; p < 0.001), patients with cancer of the vertebral column (SMR, 2.88; 95% CI, 2.13–3.83; p < 0.001) and pelvic bones (SMR, 2.75; 95% CI, 2.00–3.65; p < 0.001), and patients within the first 5 years of cancer diagnosis (SMR, 10.8; 95% CI, 9.19–12.61; p < 0.001). With identification of these characteristics that are associated with higher incidence of suicide, physicians should consider screening patients possessing these traits. By identifying at-risk patients, we can hope to reduce the incidence of suicide in this population by providing the treatment that these patients need. Further research must be done to determine how best to screen these patients and to identify the best interventions to reduce suicide incidence. Level III, prognostic study.

Background Immunoglobulin G (IgG) is an essential plasma-derived medicine that is lacking in developing countries. IgG shortages leave immunodeficient patients without treatment, exposing them to devastating recurrent infections from local pathogens. A simple and practical method for producing IgG from normal or convalescent plasma collected in developing countries is needed to provide better, faster access to IgG for patients in need. Methodology/Principal Findings IgG was purified from 10 consecutive minipools of 20 plasma donations collected in Egypt using single-use equipment. Plasma donations in their collection bags were subjected to 5%-pH5.5 caprylic acid treatment for 90 min at 31°C, and centrifuged to remove the precipitate. Supernatants were pooled, then dialyzed and concentrated using a commercial disposable hemodialyzer. The final preparation was filtered online by gravity, aseptically dispensed into storage transfusion bags, and frozen at 5 logs reduction of HIV, BVDV, and PRV infectivity in less than 15 min of caprylic acid treatment. Conclusions/Significance 90% pure, virally-inactivated immunoglobulins can be prepared from plasma minipools using simple disposable equipment and bag systems. This easy-to-implement process could be used to produce immunoglobulins from local plasma in developing countries to treat immunodeficient patients. It is also relevant for preparing hyperimmune IgG from convalescent plasma during infectious outbreaks such as the current Ebola virus episode., Author Summary Plasma-derived immunoglobulin G (IgG) is on WHO’s Essential Medicines List, yet developing countries face severe shortages of this critical treatment. Infusion of IgG prepared from locally-collected plasma provides an advantageous mix of antibodies to viral and bacterial pathogens found in the living environment, and this can reduce recurrent infections in immune-deficient patients. We developed a simple manufacturing process using disposable equipment (blood bags, hemodialyzer, and filters) to isolate immunoglobulins from minipools of 20 plasma donations. This process yields a ca. 90% pure virally-inactivated immunoglobulin fraction at 50–60% recovery. Anti-hepatitis B and anti-rubella immunoglobulins were enriched fourfold to sixfold. The product was free of in-vitro thrombogenic and proteolytic activity, confirming its expected clinical safety profile. Virus validations showed caprylic acid treatment robustly inactivated or removed infectivity of lipid-enveloped viruses, including human immunodeficiency virus (HIV) and hepatitis C virus model. This simple and cost-effective process is implemented in Egypt to prepare experimental batches for clinical evaluation. It can enhance immunoglobulin supplies to treat immunodeficient patients through passive transmission of antibodies directed against local pathogens. The method requires minimal training and reasonable infrastructure, and is a practical means to prepare convalescent hyperimmune IgG during infectious outbreaks such as the current Ebola episode.

Background Solvent/detergent (S/D) inactivates enveloped viruses in plasma. The current technology requires a plasma fractionation facility and is applied to large plasma pools, which increases the cost and risks of exposure to S/D-resistant pathogens and lowers the content of protein S and alpha2-antiplasmin. Two S/D treatment procedures for single donations or minipools of plasma have been developed with a single-use bag system. Study design and methods Frozen plasma samples were thawed and treated in disposable bags with either 2 percent tri(n-butyl)phosphate (TnBP) at 37 degrees C or 1 percent TnBP and 1 percent Triton X-45 at 31 degrees C for 4 hours. Plasma samples were extracted three times with 7.5 percent sterile castor oil to remove TnBP and Triton X-45. The TnBP-treated plasma samples were further subjected to a clarifying centrifugation (3800 x g, 30 min). Final plasma samples were dispensed into individual bags and frozen at -30 degrees C. Plasma quality was assessed at each step of the procedures. Results Both processes yielded greater than 90 percent mean recovery of coagulation factors (clottable fibrinogen, von Willebrand factor, and factors VIII, V, VII, IX, X, and XI), anticoagulants (protein C, protein S), protease inhibitors (antithrombin, alpha2-antiplasmin), total protein, albumin, and immunoglobulins. Global coagulation tests of the treated plasma samples were normal. Final TnBP and Triton X-45 content was less than 10 and 50 ppm, respectively. Conclusion S/D treatment of plasma can be performed in a closed-bag system under conditions that maintain plasma protein quality. The technology is simple, presents advantages over the industrial large-scale S/D plasma process, and could be performed in blood centers.

Background and Objectives Single-donor or small-pool cryoprecipitates are produced by blood establishments, mostly in developing countries, for substitute therapy in haemophilia A, von Willebrand disease and fibrinogen deficiency, as well as for the manufacture of fibrin sealant. As cryoprecipitate may be contaminated with pathogenic plasma-borne viruses, there is an urgent need to develop a simple method for the viral inactivation of cryoprecipitate. Materials and Methods Cryoprecipitate was obtained according to standard procedures. Ten minipools of five or six donations of cryoprecipitate were prepared and subjected, in sterile closed bags, to a viral inactivation treatment using either 2% tri(n-)butyl phosphate (TnBP) for 4 h at 37 °C or the combination of 1% TnBP and 1% Triton X-45 for 4 h at 31 °C. The cryoprecipitates were subsequently extracted three times in their processing bags by mixing and decantation using 7·5% sterile ricinus oil. The TnBP-treated cryoprecipitates were further subjected to a clarifying centrifugation step at 3800 g for 30 min. The final products were dispensed into individual bags and frozen at −30 °C or lower. Results The cryoprecipitates treated with either 2% TnBP or 1% TnBP + 1% Triton X-45 showed excellent (> 93%) mean recovery of coagulant factor VIII (FVIII), ristocetin cofactor Von Willebrand factor (VWF:RCo), and clottable fibrinogen activity. Prothrombin time, international normalized ratio and activated partial thromboplastin time increased during solvent–detergent treatment but returned to initial values after oil extractions. The final content of TnBP and Triton X-45 was