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Biomedical subjects

Mohit Bhandari

Publications and source records attributed to Mohit Bhandari.

At least 91 records · Page 5Linked to original sources
PubMed2004

Doubling the impact: publication of systematic review articles in orthopaedic journals.

BACKGROUND: Investigators aim to publish their research papers in top journals to disseminate their findings to the widest possible audience. Systematic reviews of the literature occupy the highest position in currently proposed hierarchies of evidence. We hypothesized that the number of citations (a measure of scholarly interest) for systematic reviews (or meta-analyses) published in leading orthopaedic journals would be greater than the number of citations for narrative reviews published in the same journals. METHODS: We identified fifteen journals that had high Science Citation Index impact factors for the orthopaedic subspecialty and were believed to have a higher yield of studies and reviews of scientific merit and clinical relevance. For the year 2000, six research associates applied methodological criteria to each article in each issue of the fifteen journals to determine whether the article was scientifically sound (rigorous versus nonrigorous). Of the 3916 articles identified, 2331 were original or review articles. We queried the ISI (Institute for Scientific Information) Web of Science database to ascertain, as of March 2003, the number of subsequent citations to each one of the reviews after its original publication in all journals that published both narrative and systematic reviews. RESULTS: Of the 2331 articles published across the fifteen journals in the year 2000, 110 were review articles. Only seventeen (15%) of the 110 reviews met our criteria for systematic reviews with rigor. Rigorous systematic reviews received more than twice the mean number of citations compared with other systematic or narrative reviews (13.8 compared with 6.0, p = 0.008). The rigor of a review was a significant predictor of the number of citations in other orthopaedic journals (p = 0.01). In addition, rigor was significantly associated with the number of citations in nonorthopaedic journals (p = 0.03). CONCLUSIONS: Our findings suggest that journal editors and authors can improve the relevance and scholarly interest in their reviews (as shown by the number of citations) by meeting standard guidelines for methodological rigor.

Humans↗
PubMed2004

From eminence-based practice to evidence-based practice: a paradigm shift.

Evidence-based medicine differs from the traditional approach to health care in that in addition to relying on clinical experience, expert opinion, and knowledge of pathophysiology for clinical decision-making, clinicians identify important knowledge gaps and information needs, formulate answerable questions, identify potentially relevant research, assess the validity of evidence and results, and apply research evidence to individual patients in a way that takes into account the patients' particular experiences, expectations, and values. It is becoming increasingly important that physicians learn the concepts of EBM because many EBM-related concepts have become a part of daily clinical practice. This article uses examples from orthopedics to outline EBM principles and methods and the advantages of EBM over traditional approaches. It also discusses challenges in implementing EBM and suggests EBM-related resources for physicians.

Clinical Competence↗
PubMed2003

Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures.

INTRODUCTION: The purpose of this study was to identify radiological predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. MATERIALS AND METHODS: An observational study design was employed using patient records and standardized radiological follow-up examinations as data sources. The database at a single institution was used to identify all patients with extra-articular distal radius fractures over the course of 1 year. A total of 71 patients with extra-articular distal radius fractures (50 dorsally displaced, 21 undisplaced) fulfilled the inclusion criteria. Patients were predominantly female (87%) with a pooled mean age of 64.9 years. All patients with displaced extra-articular distal radius fractures underwent closed reduction with subsequent cast immobilization. Undisplaced fractures were simply treated with cast immobilization. The primary outcomes were early (1 week) and late (6 weeks) instability of the fracture. Instability was defined as: (1) dorsal tilt >15 degrees, (2) volar tilt >20 degrees, (3) ulnar variance >4 mm, (4) radial inclination <10 degrees. RESULTS: Degree of radial shortening and volar tilt were predictive of early instability ( p<0.05), with dorsal comminution also approaching statistical significance ( p=0.06). Radial inclination, age, radial shortening, and volar tilt were predictive of late failure ( p<0.05). An unexpected result showed that one-third of undisplaced fractures went on to fail, most of which occurred in those patients over the age of 65 years. CONCLUSION: An awareness of independent predictors of instability in extra-articular distal radius fractures is helpful in anticipating the final alignment outcome.

Age Distribution↗
PubMed2003

Hierarchy of evidence: differences in results between non-randomized studies and randomized trials in patients with femoral neck fractures.

INTRODUCTION: There have been a number of non-randomized studies comparing arthroplasty with internal fixation in patients with femoral neck fractures. However, there remains considerable debate about whether the results of non-randomized studies are consistent with the results of randomized, controlled trials. Given the economic burden of hip fractures, it remains essential to identify therapies to improve outcomes; however, whether data from non-randomized studies of an intervention should be used to guide patient care remains unclear. We aimed to determine whether the pooled results of mortality and revision surgery among non-randomized studies were similar to those of randomized trials in studies comparing arthroplasty with internal fixation in patients with femoral neck fractures. MATERIALS AND METHODS: We conducted a Medline search from 1969 to June 2002, identifying both randomized and non-randomized studies comparing internal fixation with arthroplasty in patients with femoral neck fractures. Additional strategies to identify relevant articles included Cochrane database, SCISEARCH, textbooks, annual meeting programs, and content experts. We abstracted information on mortality and revision rates in each study and compared the pooled results between non-randomized and randomized studies. In addition, we explored potential reasons for dissimilar results between the two study designs. RESULTS: We identified 140 citations that addressed the general topic of comparison of arthroplasty and internal fixation for hip fracture. Of these, 27 studies met the eligibility criteria, 13 of which were non-randomized studies and 14 of which were randomized trials. Mortality data was available in all 13 non-randomized studies ( n=3108 patients) and in 12 randomized studies ( n=1767 patients). Non-randomized studies overestimated the risk of mortality by 40% when compared with the results of randomized trials (relative risk 1.44 vs 1.04, respectively). Information on revision risk was available in 9 non-randomized studies ( n=2764 patients) and all 14 randomized studies ( n=1901 patients). Both estimates from non-randomized and randomized studies revealed a significant reduction in the risk of revision surgery with arthroplasty compared with internal fixation (relative risk 0.38 vs 0.23, respectively). The reduction in the risk of revision surgery with arthroplasty compared with internal fixation was 62% for non-randomized studies and 77% for randomized trials. Thus, non-randomized studies underestimated the relative benefit of arthroplasty by 19.5%. Non-randomized studies with point estimates of relative risk similar to the pooled estimate for randomized trials all controlled for patient age, gender, and fracture displacement in their comparisons of mortality. We were unable to identify reasons for differences in the revision rate results between the study designs. CONCLUSIONS: Similar to other reports in medical subspecialties, non-randomized studies provided results dissimilar to randomized trials of arthroplasty vs internal fixation for mortality and revision rates in patients with femoral neck fractures. Investigators should be aware of these discrepancies when evaluating the merits of alternative surgical interventions, especially when both randomized trials and non-randomized comparative studies are available.

Arthroplasty, Replacement, Hip↗
PubMed2003

Assessing observational studies of spinal fusion and chemonucleolysis.

STUDY DESIGN: Literature review and survey of spine surgeons. OBJECTIVES: To identify reasons for variation in results among observational studies of spinal surgery. SUMMARY AND BACKGROUND DATA: Orthopedic treatments are often evaluated by observational studies rather than randomized controlled trials. The value of observational studies is debated. METHODS: A literature search was performed to find several observational studies that compared the same spinal surgeries. Possible confounders for these studies were identified by a survey of spinal surgeons. Study characteristics from these articles were tested for an association with study results. RESULTS: Most observational studies were case series. Articles studied in depth included 20 evaluating chemonucleolysis and 14 evaluating spinal arthrodesis for patients who had herniated disc or spinal stenosis. For each treatment comparison, results varied from strongly favoring one treatment to strongly favoring the other. Apparent causes of the variation were patient selection criteria, the choice of outcome measure, and follow-up rate. Few studies reported on the potential confounders identified by physician surveys, and only one study used statistical methods to reduce the influence of confounding. CONCLUSIONS: The results suggest that review of several comparable observational studies may help evaluate treatment, identify patient types most likely to benefit from a give treatment, and provide information about study features that can improve the design of subsequent observational or randomized controlled studies. The potential of comparative observational studies has not been realized because of current inadequacies in their design, analysis, and reporting.

Evaluation Studies as Topic↗
PubMed2003

Improving reliability in the classification of fractures of the acetabulum.

BACKGROUND: Plain radiographs of the pelvis are routinely used in the initial assessment of patients with suspected fractures of the acetabulum. It is necessary for orthopaedic resident trainees, emergency physicians as well as orthopaedic surgeons who infrequently treat trauma patients to be able to describe these fracture patterns reliably to traumatologist orthopaedic surgeons who ultimately take over the patient care. Our purpose was two-fold: (1) to determine the reliability of the component parts of the Letournel classification of acetabular fractures involving six anteroposterior (AP) radiographic lines, and (2) to examine whether the addition of oblique radiograph views (Judet views) would improve the reliability. METHODS: Thirty sets of AP and oblique radiographs (Judet views) of the pelvis were selected from a hospital database to represent various types of acetabular fractures. Six reviewers (three orthopaedic trainees and three community orthopaedic surgeons) independently reviewed the radiographs. For each radiograph, the reviewer classified the acetabular fracture according to the Letournel classification. In addition, each reviewer utilized a simplified classification scheme using six radiographic lines on the AP pelvic radiograph. Interobserver reliabilities among reviewers were reported along with the intraclass correlation coefficient (ICC) and kappa values. RESULTS: Agreement for the Letournel classification increased with increasing physician experience (trainees ICC=-0.14 and community surgeons ICC=0.56). Interobserver reliability between trainees and community surgeons improved when the six radiographic lines were used (range kappa=0.09-0.89). The oblique pelvic radiographs (Judet views) did not significantly improve reliability among physicians. CONCLUSIONS: In this study we report the following: (1) the reliability of the Letournel classification improves with level of training, (2) physicians with less experience with acetabular fractures have significantly better agreement in identifying fractures using the six radiographic lines on the AP film than the Letournel classification, and (3) agreement among the reviewers for the AP pelvic radiograph is not improved with additional oblique (Judet) views.

Acetabulum↗
PubMed2003

Limiting loss to follow-up in a multicenter randomized trial in orthopedic surgery.

Even the best-designed, randomized controlled trials suffer when patients are lost to follow-up. Incomplete follow-up biases the results of a trial when patients who drop out are different from those who complete follow-up. This is exaggerated further when there are differential dropout rates between study groups. Previous randomized controlled trials in orthopedic trauma have reported up to 28% loss to follow-up. Only by striving to achieve a 0% loss to follow-up rate can we be certain that this type of bias does not affect our results. In our ongoing multicenter, randomized controlled trial comparing reamed and nonreamed intramedullary nailing of tibial shaft fractures, we have implemented several innovative strategies to minimize loss to follow-up. The exclusion criteria and consent process are designed to minimize losses. Study staff are carefully trained in communication and negotiation with patients. Additionally, a central methods center monitors all patient follow-up and aids in finding lost patients. Through these primary, secondary, and tertiary interventions, we have achieved 94% complete 1-year follow-up for the first 440 patients enrolled in the trial. Eleven patients withdrew consent, and we are unable to locate 17 patients. We have successfully minimized the loss to follow-up rate in our trial by incorporating innovative prevention and retention strategies into its design and conduct. Through planning, organization, and committing time and resources to minimizing loss to follow-up, other orthopedic trauma trials can hope to achieve the same high rates of follow-up.

Bias↗
PubMed2003

A randomized trial of opinion leader endorsement in a survey of orthopaedic surgeons: effect on primary response rates.

BACKGROUND: Opinion leaders have been shown to have significant influence on the practice of health professionals and patient outcomes. METHODS: Using focus groups, key informants, and sampling to redundancy techniques, we developed a questionnaire of surgeons' preferences in the treatment of tibial shaft fractures. Twenty-two well-respected and widely known orthopaedic traumatologists endorsed the questionnaire. We randomized 395 surgeon members of the Orthopaedic Trauma Association to receive either a questionnaire that included a letter informing them of the opinion leaders' endorsement, or a questionnaire without the endorsement. RESULTS: Surgeons who received the letter of endorsement had a significantly lower response rate at 2, 4, and 8 weeks. The absolute difference in response rates was 7.8% (4.6% versus 12.4%, P < 0.05) at 2 weeks, 13.1% at 4 weeks (28.6% versus 41.7% P < 0.02), and 12.3% at 8 weeks (47.5% versus 59.8% P = 0.02). CONCLUSIONS: The addition of a letter listing expert surgeons who endorse the survey lead to significantly lower primary response rates. Those interested in influencing physician responses cannot always assume a positive effect from endorsement by opinion leaders

Adult↗
PubMed2003

Challenges to the practice of evidence-based medicine during residents' surgical training: a qualitative study using grounded theory.

PURPOSE: To examine surgical trainees' barriers to implementing and adopting evidence-based medicine (EBM) in the day-to-day care of surgical patients. METHOD: In 2000, 28 surgical residents from various subspecialties at a hospital affiliated with McMaster University Faculty of Health Sciences in Ontario, Canada, participated in a focus group (n = 8) and semistructured interviews (n = 20) to explore their perceptions of barriers to the practice of EBM during their training. Additional themes were explored, such as definitions of EBM and potential strategies to implement EBM during training. The canons and procedures of the grounded theory approach to qualitative research guided the coding and content analysis of the data derived from the focus group and semistructured interviews. RESULTS: Residents identified personal barriers, staff-surgeon barriers, and institutional barriers that limited their ability to apply EBM in their daily activities. Residents perceived their lack of education in EBM, time constraints, lack of priority, and fear of staff disapproval as major challenges to practicing EBM. Moreover, the lack of ready access to surgical EBM resource materials proved to be an important additional factor limiting EBM surgical practice. Residents identified several strategies to overcome these barriers to EBM, including hiring staff surgeons with EBM training, offering coursework in critical appraisal for all staff, improving interdepartmental communication, and providing greater flexibility for EBM training. CONCLUSIONS: Surgical residents identified a general lack of education, time constraints, lack of priority, and staff disapproval as important factors limiting incorporation of EBM. Curriculum reform and surgeon education may help overcome these barriers.

Adult↗
PubMed2003

Operative management of lower extremity fractures in patients with head injuries.

Treatment of patients with lower extremity fractures and concomitant head injury is controversial. The authors compared reamed intramedullary nailing versus plating of femoral and tibial fractures in patients with polytrauma and concomitant head injury. One thousand five hundred twenty-five patients with head injuries were identified from a prospective trauma database. Of those, 1211 patients sustained severe head injuries (Abbreviated Injury Score >/= 3). One hundred nineteen patients with severe head injuries and lower extremity long bone fractures met the inclusion criteria. Ultimately, four patient groups were identified: Group A, reamed femoral nail (n = 21); Group B, femoral plate (n = 29); Group C, reamed tibial nail (n = 23); and Group D, tibial plate (n = 46). Reamed intramedullary nails did not significantly alter the risk of mortality when compared with plates in femoral (relative risk 0.46; 95% confidence interval, 0.04-4.6) and tibial (relative risk 1.18; 95% confidence interval, 0.05-11.9) fractures. The severity of the initial head injury (Glasgow Coma Scale score) was the strongest predictor of mortality. Functional independence scores between patients with reamed nails and patients with plates were similar at 1 year. Head injury does not seem to be a contraindication to reamed intramedullary nailing in patients with lower extremity fractures. The severity of head injury alone is an important predictor of outcome. A large, randomized trial with sufficient study power is needed to clarify this issue.

Adolescent↗