Readability assessment of patient educational materials for pediatric spinal conditions from top academic orthopedic institutions.

Background: The Internet has become a 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 sixth grade reading level. This translates to a standardized Flesch Reading Ease Score between 81 and 90, which is equivalent to conversational English. However, previous studies have demonstrated that the readability of online education materials of various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal conditions has not been analyzed. The objective of this study was to assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal conditions. Methods: Online 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 assessed utilizing multiple readability assessment metrics including Flesch-Kincaid, Flesch Reading Ease, Gunning Fog Index, and others. Correlations between academic institutional ranking, geographic location, and the use of concomitant multimedia modalities with Flesch-Kincaid scores were evaluated using a Spearman regression. Results: Only 32% (8 of 25) of top pediatric orthopedic hospitals provided online health information at or below a sixth grade reading level. The mean Flesch-Kincaid score was 9.3 ± 2.5, Flesch Reading Ease 48.3 ± 16.2, Gunning Fog Score 10.7 ± 3.0, Coleman-Liau Index 12.1 ± 2.8, Simple Measure of the Gobbledygook Index 11.7 ± 2.1, Automated Readability Index 9.0 ± 2.7, FORCAST 11.3 ± 1.2, and Dale-Chall Readability Index 6.7 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of video material with Flesch-Kincaid scores (p = 0.1042, p = 0.7776, p = 0.3275, respectively). Conclusion: Online educational material for pediatric spinal conditions from top pediatric orthopedic institutional websites is associated with excessively complex language which may limit comprehension for the majority of the US population. Type of study/Level of evidence: Economic and Decision Analysis/level III.

Upper cervical spine instability systematic review: a bibliometric analysis of the 100 most influential publications.

Background: Instability in the upper cervical spine, although rare, can be devastating. This spectrum of conditions includes occipitocervical instability, atlantoaxial instability and atlantoaxial rotatory displacement. Knowledge of the literature can provide better understanding of disease processes and management, and aid in clinical decision making. The objective of this study was to perform a bibliometric analysis to formulate a comprehensive review of the most cited publications. Methods: A systematic search of the literature was conducted using the Clarivate Web of Science database. The search query was '"Atlanto-occipital dislocation" OR "atlanto-occipital dissociation" OR "atlantoaxial rotatory displacement" OR "atlantoaxial instability"'. The top 100 articles based on frequency of citation were included in our study. Data extracted from articles included frequency of citation, year of publication, country of origin, journal of publication, level of evidence and article type. Results: Our initial search yielded 257 results that met the criteria. Articles not pertaining to atlanto-occipital instability were removed. Citation frequency ranged from 15 to 195. The most cited article was "Traumatic Anterior Atlanto-Occipital Dislocation" published by Powers et al. in 1979. The most productive decade was 2000-2009 with 45 publications. All decades showed a progressive increase in the number of papers published except for 2010-2019. Overall, 19 countries contributed and the most productive was the United States (n=61). The articles found in our search were cited a total of 4,095 times (3,463 without self-citations) averaging 40.95 citations per publication. Discussion: The goal of a bibliometric study is to assess trends in a specific field of study, provide evidence for the impact of an individual or field of study's research, and highlight potential areas for future research. While the number of citations does not necessarily reflect publication quality, it reflects overall influence based on recognition by peers in the field. Publications from the last 20 years have emphasized the use of newer technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) to aid in diagnosis. Our study highlights the lack of high-level evidence articles and underscores that our understanding of these conditions in both pediatric and adult patients is maturing.

Readability assessment of patient educational materials for pediatric spinal deformity from top academic orthopedic institutions.

STUDY DESIGN: Cross-sectional analysis of patient educational materials from top pediatric orthopedic hospital websites. OBJECTIVE: To assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal deformity. The 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. METHODS: Online 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. RESULTS: Only 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. CONCLUSION: Online educational material for pediatric spinal deformity from top pediatric orthopedic institutional websites are associated with poor readability.

The effects of local insulin application to lumbar spinal fusions in a rat model.

BACKGROUND CONTEXT: The rates of pseudoarthrosis after a single-level spinal fusion have been reported up to 35%, and the agents that increase the rate of fusion have an important role in decreasing pseudoarthrosis after spinal fusion. Previous studies have analyzed the effects of local insulin application to an autograft in a rat segmental defect model. Defects treated with a time-released insulin implant had significantly more new bone formation and greater quality of bone compared with controls based on histology and histomorphometry. A time-released insulin implant may have similar effects when applied in a lumbar spinal fusion model. PURPOSE: This study analyzes the effects of a local time-released insulin implant applied to the fusion bed in a rat posterolateral lumbar spinal fusion model. Our hypothesis was twofold: first, a time-released insulin implant applied to the autograft bed in a rat posterolateral lumbar fusion will increase the rate of successful fusion and second, will alter the local environment of the fusion site by increasing the levels of local growth factors. STUDY DESIGN: Animal model (Institutional Animal Care and Use Committee approved) using 40 adult male Sprague-Dawley rats. METHODS: Forty skeletally mature Sprague-Dawley rats weighing approximately 500 g each underwent posterolateral intertransverse lumbar fusions with iliac crest autograft from L4 to L5 using a Wiltse-type approach. After exposure of the transverse processes and high-speed burr decortication, a Linplant (Linshin Canada, Inc., ON, Canada) consisting of 95% microrecrystalized palmitic acid and 5% bovine insulin (experimental group) or a sham implant consisting of only palmitic acid (control group) was implanted on the fusion bed with iliac crest autograft. As per the manufacturer, the Linplant has a release rate of 2 U/day for a minimum of 40 days. The transverse processes and autograft beds of 10 animals from the experimental and 10 from the control group were harvested at Day 4 and analyzed for growth factors. The remaining 20 spines were harvested at 8 weeks and underwent a radiographic examination, manual palpation, and microcomputed tomographic (micro-CT) examination. RESULTS: One of the 8-week control animals died on postoperative Day 1, likely due to anesthesia. In the groups sacrificed at Day 4, there was a significant increase in insulinlike growth factor-I (IGF-I) in the insulin treatment group compared with the controls (0.185 vs. 0.129; p=.001). No significant differences were demonstrated in the levels of transforming growth factor beta-1, platelet-derived growth factor-AB, and vascular endothelial growth factor between the groups (p=.461, .452, and .767 respectively). Based on the radiographs, 1 of 9 controls had a solid bilateral fusion mass, 2 of 9 had unilateral fusion mass, 3 of 9 had small fusion mass bilaterally, and 3 of 9 had graft resorption. The treatment group had solid bilateral fusion mass in 6 of 10 and unilateral fusion mass in 4 of 10, whereas a small bilateral fusion mass and graft resorption were not observed. The difference between the groups was significant (p=.0067). Based on manual palpation, only 1 of 9 controls was considered fused, 4 of 9 were partially fused, and 4 of 9 were not fused. In the treatment group, there were 6 of 10 fusions, 3 of 10 partial fusions, and 1 of 10 were not fused. The difference between the groups was significant (p=.0084). Based on the micro-CT, the mean bone volume of the control group was 126.7 mm(3) and 203.8 mm(3) in the insulin treatment group. The difference between the groups was significant (p=.0007). CONCLUSIONS: This study demonstrates the potential role of a time-released insulin implant as a bone graft enhancer using a rat posterolateral intertransverse lumbar fusion model. The insulin-treatment group had significantly higher fusion rates based on the radiographs and manual palpation and had significantly higher levels of IGF-I and significantly more bone volume on micro-CT.

Cervical spondylotic myelopathy: factors in choosing the surgical approach.

Cervical spondylotic myelopathy is a progressive disease and a common cause of acquired disability in the elderly. A variety of surgical interventions are available to halt or improve progression of the disease. Surgical options include anterior or posterior approaches with and without fusion. These include anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, cervical disc replacement, laminoplasty, laminectomy with and without fusion, and combined approaches. Recent investigation into the ideal approach has not found a clearly superior choice, but individual patient characteristics can guide treatment.

Forward progression of the helical blade into the pelvis after repair with the Trochanter Fixation Nail (TFN).

Unstable intertrochanteric and subtrochanteric fractures historically have been prone to inferior displacement of the femoral head as well as varus collapse. Efforts to mitigate these untoward outcomes have led to the evolution of the Trochanteric Fixation Nail (TFN) with its helical spiral blade. The TFN has many proposed advantages such as simplified insertion, less hardware, and improved resistance to "cutout" of cephallomedullary fixation. Previous case reports have shown spiral blade perforation through the femoral head and, in some cases, into the hip. However, to our knowledge, there have not been any reports describing the advancement of the helical spiral blade into the pelvic cavity. We present a case of forward advancement of the helical spiral blade through the femoral head and acetabulum into the pelvic cavity.

Stimulation of ankle cartilage: other emerging technologies (cellular, electricomagnetic, etc.).

Advances in understanding age-related changes in articular cartilage, joint homeostasis, the natural healing process after cartilage injury, and improved standards for evaluation of a joint surface made the ultimate goal of cartilage repair a possibility. New strategies for enhancement of articular cartilages' limited healing potential and biologic regeneration include advances in tissue engineering and the use of electromagnetic fields. This article reviews developments in basic science and clinical research made with these emerging technologies concerning treatment of articular cartilage defects and treatment of osteoarthritis of the ankle.

Glucosamine prevents in vitro collagen degradation in chondrocytes by inhibiting advanced lipoxidation reactions and protein oxidation.

Osteoarthritis (OA) affects a large segment of the aging population and is a major cause of pain and disability. At present, there is no specific treatment available to prevent or retard the cartilage destruction that occurs in OA. Recently, glucosamine sulfate has received attention as a putative agent that may retard cartilage degradation in OA. The precise mechanism of action of glucosamine is not known. We investigated the effect of glucosamine in an in vitro model of cartilage collagen degradation in which collagen degradation induced by activated chondrocytes is mediated by lipid peroxidation reaction. Lipid peroxidation in chondrocytes was measured by conjugated diene formation. Protein oxidation and aldehydic adduct formation were studied by immunoblot assays. Antioxidant effect of glucosamine was also tested on malondialdehyde (thiobarbituric acid-reactive substances [TBARS]) formation on purified lipoprotein oxidation for comparison. Glucosamine sulfate and glucosamine hydrochloride in millimolar (0.1 to 50) concentrations specifically and significantly inhibited collagen degradation induced by calcium ionophore-activated chondrocytes. Glucosamine hydrochloride did not inhibit lipid peroxidation reaction in either activated chondrocytes or in copper-induced oxidation of purified lipoproteins as measured by conjugated diene formation. Glucosamine hydrochloride, in a dose-dependent manner, inhibited malondialdehyde (TBARS) formation by oxidized lipoproteins. Moreover, we show that glucosamine hydrochloride prevents lipoprotein protein oxidation and inhibits malondialdehyde adduct formation in chondrocyte cell matrix, suggesting that it inhibits advanced lipoxidation reactions. Together, the data suggest that the mechanism of decreasing collagen degradation in this in vitro model system by glucosamine may be mediated by the inhibition of advanced lipoxidation reaction, preventing the oxidation and loss of collagen matrix from labeled chondrocyte matrix. Further studies are needed to relate these in vitro findings to the retardation of cartilage degradation reported in OA trials investigating glucosamine.

C4d peritubular capillary staining in chronic allograft nephropathy and transplant glomerulopathy: an uncommon finding.

The true incidence of positive C4d staining in the peritubular capillaries of biopsies with chronic allograft nephropathy (CAN) and transplant glomerulopathy (TGP) remains controversial. We retrospectively reviewed all transplant biopsies performed at Saint Louis University Hospital between June 2002 and May 2004. We examined the incidence of positive C4d staining in the peritubular capillaries of biopsy specimens with pure CAN with or without features of TGP. We identified 54 biopsies in 43 patients showing CAN. The average age was 46 +/- 13 years. The average creatinine at the time of biopsy was 308 +/- 211 micromol/l (3.5 +/- 2.4 mg/dl). Twenty (37%) biopsies exhibited features consistent with TGP. Only two biopsies had positive C4d staining in the peritubular capillaries. The C4d positive biopsies were from two different patients; one patient had donor specific antibodies (DSA) against HLA class 1 at the time of biopsy and the other patient had no detectable DSA. None of the TGP biopsies showed peritubular C4d staining. C4d staining of the peritubular capillaries appears to be rare in patients with pure CAN with and without TGP features.

Extracorporeal management of valproic acid toxicity: a case report and review of the literature.

The incidence of intentional or accidental valproic acid (VPA) overdose is increasing. Severe VPA toxicity may lead to coma and death. Traditionally the treatment of patients with VPA toxicity has been limited to supportive measures. VPA is highly protein bound and therefore it is considered not to be removable by extracorporeal means. However, studies of VPA toxicokinetics indicate that at blood levels that exceed therapeutic concentrations, VPA protein binding sites become saturated, leading to increased concentration of the free unbound drug. The free unbound drug has a small molecular weight and therefore it is theoretically amenable to removal by extracorporeal means. We present a patient with VPA toxicity who was successfully treated with "in-series" hemodialysis and hemoperfusion followed by continuous venovenous hemodiafiltration (CVVHDF) and review the literature on the management of VPA toxicity using extracorporeal therapies.